Management and outcome of intrathoracic bleeding due to vascular injury during transhiatal esophagectomy.
OBJECTIVE
The objective of this study was to ascertain the incidence and outcome of intrathoracic vascular injury during transhiatal resection of the esophagus.


BACKGROUND
Resection of the esophagus is indicated for a variety of benign and malignant diseases and can be performed via the transhiatal or transthoracic route. As the esophagus is in close vicinity to the aorta, pulmonary vessels and the azygous vein, these blood vessels can be injured during its resection.


METHODS
We extracted data on the incidence, management, and outcome of intrathoracic vascular injuries that occurred during transhiatal esophagectomy between 1983 and 2010 from a prospectively maintained esophageal diseases database.


RESULTS
During this period, 710 transhiatal esophagectomies were done for malignant (n = 617) and benign causes (n = 93). Intrathoracic vascular injury occurred in ten patients (1.4%). The indication for esophagectomy was malignancy (nine patients) and corrosive stricture (one patient). All nine patients with malignancy had squamous cell carcinoma, and the tumor was located in the midthoracic esophagus in seven and lower thoracic esophagus in two patients. Eight of nine patients with cancer had received preoperative radiotherapy. The site of injury was the aorta/its esophageal branch (six patients), azygous vein (three patients), and inferior pulmonary vein (one patient). The estimated median intraoperative blood loss was 4,450 ml (range, 2,000-6,000 ml), and the median duration of the surgery was 5 h (range, 4-7 h). On a multivariable analysis, location of tumor (in the midthoracic esophagus) was a significant risk factor for the occurrence of vascular injury. Seven patients required a thoracotomy to control the bleeding while in two patients, it could be identified and controlled transhiatally. Two patients died intraoperatively due to massive bleeding and another two died in the postoperative period. Of the patients who survived (n = 6), three patients had an uneventful recovery, one patient developed a cervical anastomotic leak, and two patients developed chest infection.


CONCLUSIONS
Vascular injury during transhiatal esophagectomy is a rare but life-threatening complication. There may be a higher risk in tumors located in the mid esophagus. Management involves prompt identification and control via a dilated hiatus or a thoracotomy.
Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, First Floor, P.C. Block, Ansari Nagar, New Delhi 110029, India. javedamitdr@gmail.com
Amit
A
Javed
Sujoy
S
Pal
Gaurav Nitin
GN
Chaubal
Peush
P
Sahni
Tushar Kanti
TK
Chattopadhyay
D000328:Adult; D000368:Aged; D001011:Aorta / Q000293:injuries; D001401:Azygos Vein / Q000293:injuries; D016063:Blood Loss, Surgical / Q000401:mortality; D002294:Carcinoma, Squamous Cell / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D004938:Esophageal Neoplasms / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D004940:Esophageal Stenosis / Q000139:chemically induced / Q000601:surgery; D016629:Esophagectomy / Q000009:adverse effects*; D005260:Female; D006801:Humans; D015994:Incidence; D007431:Intraoperative Complications / Q000209:etiology* / Q000401:mortality / Q000601:surgery; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D019106:Postoperative Hemorrhage / Q000209:etiology* / Q000401:mortality; D011667:Pulmonary Veins / Q000293:injuries; D012307:Risk Factors; D013537:Sutures; D013908:Thoracotomy; D057772:Vascular System Injuries / Q000150:complications* / Q000601:surgery