title: Injury to the major airways during subtotal esophagectomy: incidence, management, and sequelae.
abstract: OBJECTIVE
  The objective of this study was to gain insight into the incidence and sequelae of injury to the major airways during subtotal esophagectomy.
  
  
  METHODS
  We performed an analysis of 383 consecutive patients undergoing this procedure between 1993 and 1999. Indications were adenocarcinoma (220), squamous cell carcinoma (121), and other (42). Transhiatal resection was done in 269 (70%) patients and transthoracic resection in 114 (30%).
  
  
  RESULTS
  There were 4 men and 2 women (median age 57 years; range 45 to 68 years) with injury to the major airways, recognized during surgery in 5 patients and on the first postoperative day in the other. Five lesions occurred during transhiatal resection (5 of 269 = 1.8%) and 1 during transthoracic resection (1 of 114 = 0.8%; P =.67). The injury occurred proximal to the carina in 5 patients and in the left main bronchus in the other. All injuries could be closed primarily. The defect was covered with pericardium in 1 patient and with pleura in 2 patients. In all cases the gastric tube was placed over the defect. Pulmonary complications developed in 4 patients. Patients with tracheal injury required artificial ventilation for a longer period (median 6 days vs 1 day; P =.02) and stayed longer in the intensive care unit (median 11 vs 3 days; P <.01) than patients without such injury, although hospital time was not significantly prolonged (median 23 vs 16 days; P =.09). There was no associated mortality.
  
  
  CONCLUSIONS
  Tracheobronchial injury is a rare complication of subtotal esophagectomy. It can be managed effectively by primary closure and apposition of vital tissue (gastric tube) to the defect. It is associated with pulmonary complications, leading to prolonged assisted ventilation and stay in the intensive care unit, but mortality is rare.
authors.affiliation: Departments of Surgery, Cardio-pulmonary Surgery, and Anesthesiology, Academic Medical Center at the University of Amsterdam, Amsterdam, The Netherlands. J.B.Hulscher@AMC.UVA.NL
authors.forename: J B
authors.initials: JB
authors.lastname: Hulscher
authors.forename: E
authors.initials: E
authors.lastname: ter Hofstede
authors.forename: J
authors.initials: J
authors.lastname: Kloek
authors.forename: H
authors.initials: H
authors.lastname: Obertop
authors.forename: P
authors.initials: P
authors.lastname: De Haan
authors.forename: J J
authors.initials: JJ
authors.lastname: Van Lanschot
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery; D000368:Aged; D001980:Bronchi / Q000293:injuries*; D002294:Carcinoma, Squamous Cell / Q000601:surgery; D004938:Esophageal Neoplasms / Q000601:surgery; D016629:Esophagectomy / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D015994:Incidence; D007431:Intraoperative Complications / Q000453:epidemiology / Q000209:etiology / Q000601:surgery; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D010496:Pericardium / Q000637:transplantation; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000706:statistics & numerical data; D012307:Risk Factors; D013997:Time Factors; D014132:Trachea / Q000293:injuries*