original papers - Advances in Clinical and Experimental Medicine

original papers - Advances in Clinical and Experimental Medicine

ORIGINAL PAPERS
Adv Clin Exp Med 2006, 15, 5, 817–826
ISSN 1230−025X
© Copyright by Silesian Piasts
University of Medicine in Wrocław
MARTA STRUTYŃSKA−KARPIŃSKA1, KRYSTYNA MARKOCKA−MĄCZKA1,
KRZYSZTOF GRABOWSKI1, MIROSŁAW NIENARTOWICZ1, ASHRAF ALASHI2
Multifactorial Analysis of Respiratory Complications
in Patients After Subtotal Esophagectomy
Because of Cancer
Wieloczynnikowa analiza powikłań ze strony układu oddechowego
u chorych poddanych subtotalnej resekcji przełyku z powodu raka
1
2
Department and Clinic of Gastrointestinal and General Surgery, Silesian Piasts University of Medicine
in Wrocław, Poland
Department and Division of Family Medicine, Silesian Piasts University of Medicine in Wrocław, Poland
Abstract
Background. Esophageal resection performed by a conventional method or using less invasive techniques is usu−
ally associated with a number of postoperative complications. Among these, respiratory complications constitute
one of the major groups.
Objectives. Analysis of respiratory complications in patients after transthoracic esophagectomy because of cancer.
Material and Methods. The retrospective analysis involved 32 patients. The parameters age, sex, and tumor loca−
tion, stage, and histopathology were assessed. The condition of the patients’ nutrition was evaluated on the basis
of BMI. Respiratory function prior to surgery was assessed by spirometric and gasometric tests. Hemoglobin level,
leukocyte count including the percentage of lymphocytes, and total serum protein were assessed prior to and 1, 3,
5, and 7 days after surgery.
Results. The patients were divided into three groups according to respiratory complications: I (n = 13) without
complication, II (n = 10) with non−life−threatening complications, and III (n = 9) with severe complications. Overall
mortality was 9.4%. The respiratory complications correlated with the observed preoperative decreased values of
the spirometric tests and pO2 and increased pCO2. Spirometry was normal in group I patients and significantly
decreased in group III (p < 0.05). Decreases in total serum protein on successive days after surgery were highest
in group III patients and this was statistically significant in relation to group I (p < 0.05). The level of lymphocytes
showed a downward trend in all groups, but only in group III patients was it below 1000/mm3.
Conclusions. Impaired pulmonary function is a significant risk factor for respiratory complications after transtho−
racic esophagectomy. The decreases in serum lymphocyte levels as well as total serum protein in successive post−
operative days are also considered unfavorable prognostic factors (Adv Clin Exp Med 2006, 15, 5, 817–826).
Key words: esophageal cancer, esophagectomy, respiratory complications.
Streszczenie
Wprowadzenie. Zabiegi resekcyjne przełyku, wykonywane sposobem konwencjonalnym lub z wykorzystaniem
technik mniej inwazyjnych, są obarczone pokaźnym odsetkiem różnorakich powikłań pooperacyjnych. Wśród nich
powikłania pochodzące z układu oddechowego zajmują istotną pozycję.
Cel pracy. Analiza powikłań dotyczących układu oddechowego wśród chorych po przezklatkowym wycięciu prze−
łyku z powodu raka.
Materiał i metody. Retrospektywną analizą objęto grupę 32 chorych. Ocenie poddano wiek i płeć chorych, umiej−
scowienie guza, stopień zaawansowania i postać histologiczną. Stan odżywienia pacjentów analizowano na pod−
stawie BMI. Wydolność oddechową przed operacją oceniano na podstawie wskaźników spirometrycznych i gazo−
metrycznych. Analizowano również stężenie hemoglobiny, liczbę leukocytów, w tym odsetek limfocytów oraz stę−
żenie białka całkowitego w surowicy przed operacją i w 1., 3., 5. i 7. dobie pooperacyjnej.
Wyniki. Pacjentów podzielono na trzy grupy w zależności od wystąpienia powikłań pochodzących z układu odde−
chowego: grupa I (13) – bez powikłań, II (10) – z powikłaniami niezagrażającymi życiu, III (9) – z ciężkimi po−
818
M. STRUTYŃSKA−KARPIŃSKA et al.
wikłaniami. Śmiertelność wynosiła 9,4%. Wystąpienie powikłań oddechowych w okresie pooperacyjnym korelo−
wało z obniżonymi w badaniach przedoperacyjnych wynikami zarówno testów spirometrycznych oraz wartościa−
mi pO2, jak i podwyższonymi stężeniami pCO2 we krwi żylnej. U pacjentów z grupy I spirometria była prawidło−
wa, a wśród pacjentów z grupy III średnie wartości tych wskaźników były istotnie obniżone (p < 0,05). Stężenie
białka całkowitego w surowicy w kolejnych dniach pooperacyjnych było najmniejsze w grupie III i było istotne
statystycznie w porównaniu z grupą I (p < 0,05). Liczba limfocytów wykazywała tendencję spadkową we wszyst−
kich grupach, ale tylko wśród pacjentów z grupy III jej wartości wynosiły poniżej 1000/mm3.
Wnioski. Zaburzenie funkcji układu oddechowego, stwierdzane w badaniach przedoperacyjnych, jest znaczącym
czynnikiem ryzyka wystąpienia powikłań po przezklatkowym wycięciu przełyku. Zarówno spadek liczby limfocy−
tów, jak i stężenia białka całkowitego w surowicy w kolejnych dniach pooperacyjnych można rozważać jako nie−
korzystny czynnik prognostyczny (Adv Clin Exp Med 2006, 15, 5, 817–826).
Słowa kluczowe: rak przełyku, wycięcie przełyku, powikłania oddechowe.
Among the various malignancies of the alimen−
tary canal, cancer of the thoracic segment of the
esophagus has one of the poorest prognoses [1]. The
clinical symptoms develop relatively late, most
commonly when the disease has already reached an
advanced clinical stage. The anatomy of the esoph−
agus, and especially the lack of serous membrane as
well as the exceptionally rich lymphatic network,
predispose to a quick spread of the malignancy.
Patients not exceeding stage III of the disease
according to the UICC (Union Internationale
Contre le Cancer) classification [2] are qualified for
esophagectomy. Esophageal resection performed by
a conventional method or using less invasive tech−
niques is usually associated with a number of post−
operative complications. Among these, respiratory
complications constitute one of the major groups
and their incidence, according to various authors,
may range from 3–5% to 20% [3–6].
An analysis of the prevalence of esophageal
cancer shows that the disease most commonly
involves people between 60 and 70 years of age in
whom the efficiency of the respiratory system has
been compromised to various extents by past or
chronic respiratory conditions, which in an obvi−
ous way affects the development of postsurgical
respiratory complications [5–7]. Malnutrition of
the patients resulting from dysphagia is another
factor significantly affecting the incidence of post−
surgical complications [8].
Basic accessory investigations performed
before the operation in patients with esophageal
cancer include endoscopic evaluation of the esoph−
agus and the bronchial tree combined with biopsies
taken for histopathological examination, radiologi−
cal assessment of the esophagus with the use of
contrast medium, ultrasound examination of the
neck and abdomen, as well as intraesophageal ultra−
sound examination and, more recently, positron
tomography and intraesophageal ultrasonography
accompanied by thin−needle biopsy of the mediasti−
nal lymph nodes [1, 6, 9]. Preoperative evaluation
of respiratory efficiency is primarily based on gaso−
metric and spirometric examinations [3, 10].
Esophageal resection using conventional meth−
ods is associated with the necessity of opening the
thorax, abdominal cavity, and the neck and is surgi−
cally extremely invasive, which obviously creates
a significant burden to the patient. However, only
radical surgery with extensive lymphadenectomy
offers any chances for prolonged survival [3, 4].
It seems that correct preoperative evaluation
of the tumor stage and respiratory system efficien−
cy as well as the general condition and nutritional
status of the patient qualified for esophageal resec−
tion significantly affect the incidence of peri− and
postoperative complications.
The aim of the study was to evaluate the inci−
dence and kind of respiratory system complica−
tions in patients submitted to esophagectomy due
to tumor in the thoracic part.
Material and Methods
From January 2001 to December 2004 a total of
212 patients with esophageal tumor were treated at
the clinic. Of these, 32 patients with stage III of the
disease according to the UICC classification were
qualified for surgical treatment. The remaining 180
patients with stage IV tumors received palliative
treatment instead of resection of the esophagus.
The retrospective analysis involved the group
of 32 patients treated by esophagectomy. The
study group included 5 women and 27 men aged
43 to 76 years (median: 57). Esophageal resection
was performed under general anesthesia with the
right thoracic approach in all the patients. The tho−
racic esophagus and posterior mediastinal lymph
nodes were resected in one block, and the pleural
cavity was drained. Next the abdominal portion of
the esophagus as well as the cardiac orifice of the
stomach with perigastric lymph nodes (in the
region of the fundus of the stomach and along the
left gastric artery) were resected by the peritoneal
approach and an alimentation gastric fistula was
performed. The cervical esophagus was isolated
through an incision along the left sternocleidomas−
Respiratory Complications After Esophagectomy
toid muscle and the salivary fistula was performed
by the cervical approach. In the postoperative peri−
od, intensive breathing exercises were carried out
for which the patients had already been prepared
before surgery. In patients requiring respiratory
assistance, careful hygiene of the bronchial tree
was maintained in the postoperative period.
The investigations were based on multifactori−
al analysis involving the evaluation of certain para−
meters before and after the operation and their cor−
relation with respiratory complications observed
after the procedure. The analysis included the
patients’ age and sex, location of the tumor, stage
of the disease according to the UICC, histology and
histological grading of the tumor, duration of the
surgery, as well as the nutritional status of the
patients as expressed by their BMIs (Body Mass
Indexes). Respiratory efficiency prior to surgery
was evaluated on the basis of spirometric tests
(VC: vital capacity, FVC: forced expiratory vital
capacity, FEV1: forced expiratory volume in 1 sec−
ond, FEV1%VC: Tiffeneau−index, PEF: peak expi−
ratory flow) and venous blood gasometry (blood
pH, pO2: partial oxygen pressure, pCO2: partial
pressure of carbon dioxide, BE: base excess).
Moreover, certain laboratory parameters, such as
hemoglobin, WBC (white blood cells) including
the level of lymphocytes, and total serum protein,
were evaluated. The same parameters were investi−
gated 1, 3, 5, and 7 days after surgery.
The patients were divided into three groups
according to the kind and character of respiratory
complications: group I included patients who did
not develop any complications, group II patients
with non−life−threatening complications (atelecta−
sis in the lower lobes, fluid in the pleural cavity
not requiring puncture, minor inflammatory focus
in one lung), and group III contained patients who
developed life−threatening complications (signifi−
cant atelectasis, fluid in the pleural cavity above
the level of the fifth rib, massive inflammatory
changes, pneumothorax on the left side, respirato−
ry insufficiency).
Evaluation of statistical significance for para−
meters with distributions differing from normal
was performed by means of the non−parametric
Fisher−Snedecor test.
Results
Among the 32 patients submitted to eso−
phagectomy due to tumor, the percentage of men
who developed complications (84.4%) was much
higher than of women. The tumor was most com−
monly localized in the upper or middle thoracic
part of the esophagus (68.8%), while, histological−
819
ly, 81.3% of cases developed squamous cell carci−
noma. The histological grading identified 28.1%
grade I, 37.5% grade II, and 34.4% grade III
tumors. Most of our patients were in stages IIA,
IIB, and III of the disease (total: 90.7%). The medi−
an duration of surgery was six hours (Table 1).
Uneventful postoperative course (group I) was
observed in 13 (40.6%) patients, non−life−threaten−
ing complications (group II) occurred in 10
(31.3%) patients, while 9 (28.1%) patients devel−
oped severe respiratory complications which
resulted in three deaths. The mortality rate was
9.4% (Table 2).
The findings of preoperative spirometric
examinations (VC, FVC, FEV1, FEV1%VC, and
PEF) were normal in group I, had borderline val−
ues in group II, and were significantly decreased in
group III patients, this difference being statistical−
ly significant in relation to the findings in group
I patients (p < 0.05) (Table 3). Analysis of indi−
vidual findings revealed that ventilation distur−
bances in one patient suffering from pneumoco−
niosis were of restrictive nature, while in the
remaining patients they were of a mixed, restric−
tive−obturative kind. Normal nutritional status was
found in 50.0% of the patients, while a further
31.3% demonstrated undernourishment to various
degrees (Table 4).
Gasometric parameters prior to surgery are
presented in Table 5, while pO2 and pCO2 levels in
successive postoperative days are presented in
Figs. 1 and 2. Mean pO2 levels in groups II and III
were below the norm (70 mm Hg). Patients in
group III had the lowest levels, which differed sta−
tistically from group I (p < 0.05). No statistically
significant difference was revealed on successive
days.
Mean preoperative levels of hemoglobin, total
serum protein, WBC, and lymphocytes were with−
in the norm in all the investigated groups.
A decrease in total serum protein was observed on
successive days after surgery, but it started to
increase from the fifth postoperative day. The
decrease was the highest in group III patients
(from 66.8 g/l to 44.7 g/l) and was statistically sig−
nificant in relation to group I (p < 0.05) (Fig. 3).
Hemoglobin medians were also lower in the post−
operative course, but the differences were not sta−
tistically significant (Fig. 4). WBC increased sig−
nificantly in the first 24 hours after surgery, and
the increase was the highest in group I patients, but
without any statistically significant differences in
relation to the remaining groups (Fig. 5). On the
other hand, the level of lymphocytes demonstrated
a downward trend and the lowest values were also
observed in the first 24 hours after surgery, but
only in patients in group III was the mean level
820
M. STRUTYŃSKA−KARPIŃSKA et al.
Table 1. Characteristics of the investigated patients
Tabela 1. Charakterystyka badanych chorych
Parameter
(Wskaźnik)
Group I
(Grupa I)
Group II
(Grupa II)
Group III
(Grupa III)
Total
(Razem)
Number (Liczba)
13 (40.6%)
10 (31.3%)
9 (28.1%)
32
Sex (Płeć)
female (żeńska)
male (męska)
2
11
2
8
1
8
5 (15.6%)
27 (84.4%)
Age (Wiek)
median (mediana)
mean ± SD (średnia ± SD)
57
57.4 ± 9.26
54
53.6 ± 7.32
64
61.22 ± 10.39
57
57.3 ± 9.25
Location of the tumor in the esophagus
(Umiejscowienie guza w przełyku)
upper third (1/3 górna)
mid third (1/3 środkowa)
lower third (1/3 dolna)
1
9
3
2
5
3
3
2
4
6 (18.8%)
16 (50.0%)
10 (31.2%)
Histopathology (Histologia)
squamous cell carcinoma (rak płaskonabłonkowy)
adenocarcinoma (rak gruczołowy)
10
3
8
2
8
1
26 (81.3%)
6 (18.7%)
Degree of tumor differentiation
(Stopień zróżnicowania) I
II
III
6
3
4
1
6
3
2
3
4
9 (28.1%)
12 (37.5%)
11 (34.4%)
Preoperative assessment of disease stage according
to UICC
(Przedoperacyjny stopień zaawansowania wg UICC)
I
IIA
IIB
III
4
2
7
1
4
2
3
3
2
4
1 (3.1%)
11 (34.4%)
6 (18.7%)
14 (43.8%)
Duration of the operation – hours
(Czas operacji – godz.) median (mediana)
mean ± SD (średnia ± SD)
6
6.35 ± 1.47
6
6.55 ± 1.42
7
6.72 ± 1.42
6
6.47 ± 1.4
Accompanying or past chronic respiratory disorders
(Współistniejące lub przebyte przewlekłe choroby
układu oddechowego)
2 (bronchial
3 (pneumoco−
asthma, tuber− niosis, tuber−
culosis)
culosis,
COPD)
5 (15.6%)
Mean ± SD – mean ± standard deviation; COPD – chronic obturative pulmonary disease.
Średnia ± SD – średnia ± odchylenie standardowe.
below 1000/mm3, and it remained low until the
seventh day after the operation (Fig. 6).
Discussion
Carcinoma of the esophagus is the fifth most
prevalent tumor among gastrointestinal cancers and
it usually affects middle−aged and older men. The
tumor is most commonly localized in the upper and
middle thoracic part of the esophagus [1, 3]. In
European countries, squamous cell carcinoma rep−
resents the most common histological form [6].
In the investigated group of patients, the men
to women ratio was 5.4 to 1 and the mean age was
57 years. The tumor involved the upper or middle
thoracic part of the esophagus in the majority of
the patients (68.8%), while in 31.2% of cases it
was localized in the supradiaphragmatic part of the
esophagus. Squamous cell carcinoma accounted
for 81.3% of cases, while adenocarcinoma was
diagnosed in 18.7% of cases. Histological grading
identified 21 grade I or grade II tumors (65.6%)
and 11 grade III tumors (34.4%). Our observations
are consistent with those of the majority of
European authors. Bonavina et al. [6], in a collec−
tive review of observations from 17 European cen−
ters, reported that in a group of 12,761 patients
with esophageal or cardiac orifice tumor, squa−
mous cell carcinoma accounted for 76.3% and
adenocarcinoma for 23.7% of cases. Resection
surgery was possible only in about 50% of patients
with squamous cell carcinoma. Schneiden et al.
[11] remarks that the incidence of esophageal
tumor has been constant for years; however, its
incidence among women has been increasing
821
Respiratory Complications After Esophagectomy
Table 2. Types of complications
Tabela 2. Rodzaje powikłań
Type of complication
(Rodzaj powikłania)
Group I
(Grupa I)
n = 13
No complications
(Bez powikłań)
13
Group II Group III
(Grupa II) (Grupa III)
n = 10
n=9
Atelectasis in lower lobes
(Niedodma w dolnych płatach)
7
Fluid in pleural cavity not requiring puncture
(Płyn w jamie opłucnowej niewymagający punkcji)
6
Minor inflammatory foci in one lung
(Drobne ognisko zapalne w jednym płucu)
5
Significant atelectasis
(Masywna niedodma)
2
Fluid above the 5th rib
(Płyn powyżej 5. żebra)
4
Massive inflammatory changes
(Rozległe zmiany zapalne)
3
Left−side pneumothorax
(Lewostronna odma)
3
Respiratory failure
(Niewydolność oddechowa)
4
Death
(Zgon)
3
Table 3. Preoperative spirometric parameters
Tabela 3. Przedoperacyjne wskaźniki spirometryczne
Feature – % of normal values
(Wskaźnik – % wartości należnej)
Group I
(Grupa I)
Group II
(Grupa II)
Group III
(Grupa III)
VC*
Me
Mean ± SD
102
106.3 ± 12.4
87.5
85.5 ± 8.69
76.6
74.4 ± 20.89
FVC*
Me
Mean ± SD
110
113.6 ± 9.29
90.1
91.5 ± 11.87
80.4
77.1 ± 15.69
FEV1*
Me
Mean ± SD
119
119.6 ± 8.76
97.1
98.7 ± 12.32
61.9
60.5 ± 9.34
FEV1%VC
Me
Mean ± SD
108
107.6 ± 5.1
106.5
105.1 ± 6.05
84.3
82.2 ± 17.16
PEF*
Me
Mean ± SD
68.4
70.3 ± 13.84
70.4
80.3 ± 22.67
31.5
33.5 ± 8.19
Group I vs. Group III p < 0.05.
VC – vital capacity.
FVC – forced expiratory vital capacity.
FEV1 – forced expiratory volume in 1 second.
FEV1%VC – Tiffeneau−index.
PEF – peak expiratory flow.
Me – median.
Mean ± SD – mean ± standard deviation.
Grupa I vs. grupa II, p < 0,05.
VC – pojemność życiowa.
FVC – natężona pojemność życiowa.
FEV1 – natężona pojemność wydechowa
pierwszosekundowa.
FEV1%VC – współczynnik Tiffeneau.
PEF – szczytowy przepływ wydechowy.
Me – mediana.
Mean ± SD – wartość średnia ± odchylenie
standardowe.
slowly but steadily. In his report the men to
women ratio was 3 to 1. Our investigations did not
confirm this trend. Slightly different observations
from ours are presented in American literature.
The last decade demonstrated a significant
increase in the rate of patients with adenocarcino−
ma [1]. The reasons for this phenomenon are
unclear. As remarked by Wild et al. [12], it may be
822
M. STRUTYŃSKA−KARPIŃSKA et al.
Table 4. Preoperative nutritional condition of the patients
Tabela 4. Przedoperacyjna ocena stopnia odżywienia
BMI (kg/m2)
Group I
(Grupa I)
n = 13
< 17
severe undernourishment
(ciężkie niedożywienie)
1
17–17.9
undernourishment
(niedożywienie)
1
18–19.9
presumptive undernourishment
(podejrzenie niedożywienia)
2
20–24.9
normal
(norma)
7
4
25–29.9
overweight
(nadwaga)
2
4
Group II
(Grupa II)
n = 10
Group III
(Grupa III)
n=9
Total
(Razem)
1 (3.1%)
2
3
6 (18.8%)
1
3 (9.4%)
5
16 (50.0%)
6 (18.7%)
BMI – Body Mass Index.
BMI – wskaźnik masy ciała.
Table 5. Preoperative gasometric parameters
Tabela 5. Przedoperacyjne wskaźniki gazometryczne
Parameter
(Wskaźnik)
Group I
(Grupa I)
Group II
(Grupa II)
Group III
(Grupa III)
pH
Me
Mean ± SD
7.419
7.41 ± 0.02
7.418
7.419 ± 0.32
7.402
7.397 ± 0.047
pO2 (mm Hg)*
Me
Mean ± SD
74.5
74.8 ± 8.0
69.85
69.28 ± 6.6
64.4
63.95 ± 6.73
pCO2 (mm Hg)
Me
Mean ± SD
39.7
38.42 ± 4.36
39.45
38.9 ± 3.3
40.7
40.47 ± 2.65
BE (mEq/l)
Me
Mean ± SD
1.2
0.68 ± 3.31
1.15
0.92 ± 2.6
1.3
0.33 ± 2.64
Group I vs. Group III, p < 0.05.
Me – median.
Mean ± SD – Mean ± standard deviation.
Grupa I vs. grupa III, p < 0,05.
Me – mediana.
Mean ± SD – wartość średnia ± odchylenie standardowe.
possible that gastroesophageal reflux is a potent
risk factor both for tumor and for a precancerous
state, such as Barrett’s esophagus. Similar sugges−
tions were put forward by Turcotte et al. [13], who
stressed that Barrett’s esophagus may be one,
although not the only one, of the reasons of the
observed increase in the incidence of adenocarci−
noma of the esophagus.
The review of literature shows that a signifi−
cant number of patients are in advanced stage of
the disease when they are first diagnosed and pal−
liative therapy remains the only option they can be
offered. In the study by Quint et al. [14] as many
as 18% of patients had remote metastases at the
time of diagnosis. The analysis of our material
demonstrates a similar trend. Of 212 patients
referred for surgical treatment, 84.9% were in
stage IV of the disease on admission to the hospi−
tal. The majority of the 32 patients qualified for
esophagectomy (96.8%) were in stages IIA, IIB,
or III of the disease. We had only one patient in
stage I. Leading American and Japanese centers
report much more favorable results in diagnosing
early forms of esophageal cancer, which is the
effect of wide−scale screening tests for subjects
with high risk factors for the disease [1, 4].
Radical resection of the esophagus, regardless
of the surgical approach, is burdened with a high
rate of postsurgical complications of the respirato−
ry system [3–5, 7]. The conventionally applied
radical methods are highly invasive to the chest
and mediastinum, which results in significant
hypofunction of the respiratory system in the post−
operative period. Ikeguchi et al. [15], comparing
823
Respiratory Complications After Esophagectomy
pO2
(mm Hg)
80
Group I/Grupa I
Group II/Grupa II
Group III/Grupa III
70
serum
hemoglobin
hemoglobina
w surowicy
(g/dl)
16
Group I/Grupa I
Group II/Grupa II
Group III/Grupa III
60
*
50
14
12
40
NS
10
30
8
20
6
10
4
0
2
prior to surgery
przed operacją
1 day
1. doba
3 day
3. doba
5 day
5. doba
7 day
7. doba
Fig. 1. Median partial pressure of oxygen (mm Hg) in
groups I, II, and III prior to surgery and at 1, 3, 5, and
7 postoperative days (* group I vs. group III, p < 0.05)
Ryc. 1. Mediany ciśnienia parcjalnego tlenu w gru−
pach I, II i III przed operacją oraz w 1., 3., 5. i 7.
dobie pooperacyjnej (* grupa I vs. grupa III, p < 0.05)
pO2
(mm Hg)
Group I/Grupa I
Group II/Grupa II
0
prior to surgery
przed operacją
1 day
1. doba
3 day
3. doba
5 day
5. doba
7 day
7. doba
Fig. 4. Median serum hemoglobin levels (g/dl) in
groups I, II, and III prior to surgery and at 1, 3, 5, and
7 postoperative days (NS – not significant)
Ryc. 4. Mediany stężenia hemoglobiny w surowicy
(g/dl) w grupach I, II i III przed operacją oraz w 1., 3., 5.
i 7. dobie pooperacyjnej (NS – nieistotne statystycznie)
Group III/Grupa III
serum
leukocytes
leukocyty
w surowicy
(mm–3)
50
40
NS
Group I/Grupa I
Group II/Grupa II
Group III/Grupa III
12000
30
10000
20
8000
10
6000
NS
4000
0
prior to surgery
przed operacją
1 day
1. doba
3 day
3. doba
5 day
5. doba
7 day
7. doba
Fig. 2. Median partial pressure of carbon dioxide
(mm Hg) in groups I, II, and III prior to surgery and at
1, 3, 5, and 7 postoperative days (NS – not significant)
Ryc. 2. Mediany ciśnienia parcjalnego dwutlenku
węgla w grupach I, II i III przed operacją oraz
w 1., 3., 5. i 7. dobie pooperacyjnej (NS – nieistotne
statystycznie)
serum
protein
białko
w surowicy
(g/l)
Group I/Grupa I
Group II/Grupa II
Group III/Grupa III
80
70
2000
0
prior to surgery
przed operacją
1 day
1. doba
3 day
3. doba
5 day
5. doba
7 day
7. doba
Fig. 5. Median serum leukocytes levels (/mm3) in
groups I, II, and III prior to surgery and at 1, 3, 5, and
7 postoperative days (NS – not significant)
Ryc. 5. Mediany liczby leukocytów w surowicy (mm–3)
w grupach I, II i III przed operacją oraz w 1., 3., 5. i 7.
dobie pooperacyjnej (NS – nieistotne statystycznie)
serum
lymphocytes
limfocyty
w surowicy
(mm–3)
Group I/Grupa I
Group II/Grupa II
Group III/Grupa III
3000
60
*
50
40
2500
2000
30
1500
20
1000
10
0
500
prior to surgery
przed operacją
1 day
1. doba
3 day
3. doba
5 day
5. doba
7 day
7. doba
Fig. 3. Median serum protein level (g/l) in groups I, II,
and III prior to surgery and at 1, 3, 5, and 7 postopera−
tive days (* group I vs. group III, p < 0.05)
Ryc. 3. Mediany stężenia białka w surowicy (g/l)
w grupach I, II i III przed operacją oraz w 1., 3., 5. i 7.
dobie pooperacyjnej (* grupa I vs. grupa III, p < 0.05)
0
prior to surgery
przed operacją
1 day
1. doba
3 day
3. doba
5 day
5. doba
7 day
7. doba
Fig. 6. Median serum lymphocytes levels in groups I,
II, and III prior to surgery and at 1, 3, 5, and 7 postop−
erative days
Ryc. 6. Mediany liczby limfocytów w surowicy
w grupach I, II i III przed operacją oraz w 1., 3., 5. i 7.
dobie pooperacyjnej
824
two groups of patients, i.e. after open esophagec−
tomy and after the transhiatal procedure, found
that significant impairment of the respiratory func−
tion in patients after open esophagectomy persists
for more than 6 months after surgery (VC and
FEV1 were 78% and 72% of the preoperative lev−
els, respectively). In contrast, the incidence of res−
piratory complications after open esophagectomy
and the transhiatal procedure did not differ signif−
icantly. However, data from less invasive surgical
modalities, especially the thoracoscopic method,
presented by other authors are not uniform. Osugi
et al. [4] reported a marked decrease in the inci−
dence of complications after the thoracoscopic
method which reached 5%, but the procedure had
to be performed by an experienced and well−
trained surgeon. The report by Fukunagi et al. [16]
seems to confirm the superiority of less invasive
procedures in comparison with open thoracotomy.
They demonstrated that the levels of proinflamma−
tory cytokines are significantly lower following
the thoracoscopic procedure in comparison with
the conventional method. Similar observations
concerning mini−thoracotomy/laparotomy are pre−
sented by Narumiya et al. [17]. However, other
authors do not share these opinions [18, 19]. Some
suggest that radical lymphadenectomy is possible
only at open thoracotomy, others that thoracoscop−
ic methods prolong significantly the time of the
surgery, while still others do not see any differ−
ences in the incidence of complications following
conventional and less invasive modalities of treat−
ment such as transhiatal esophagectomy [4,
18–20]. Our investigations did not resolve the
question, as the transthoracic operation was the
preferred surgical method. It seems that the final
answer should be expected after a multi−center
study on a large population using various surgical
modalities and taking into account remote survival
rates.
The review of literature concerning risk fac−
tors for respiratory complications in patients after
esophagectomy indicates that the main risk factors
include age over 65 years, low body mass, as well
as coexisting chronic disorders in other systems
[5, 7, 8]. Moreover, independent risk factors
include abnormal preoperative spirometric and
gasometric findings, which point to hypofunction
of the respiratory system [20].
In the study group, severe respiratory compli−
cations occurred in 28.1% of the patients and the
associated mortality rate was 9.4%. These obser−
vations are similar to the results presented by
Marmuse et al. [7], where severe respiratory com−
plications affected 36% of patients after
esophagectomy with chronic obstructive pul−
monary disease and the associated mortality rate
M. STRUTYŃSKA−KARPIŃSKA et al.
was 10%. It is worth noting that the authors used
transhiatal esophagectomy, which is considered
a significantly less invasive modality than our
open approach. Griffin et al. [3], in their study on
228 patients with subtotal resection of the esopha−
gus by means of the Ivor Lewis method, observed
severe respiratory complications in 17% of the
operated patients. The complications closely cor−
related with low values of preoperative spiromet−
ric tests. Similar observations have been reported
by other authors [10, 20]. Avendano et al. [10]
demonstrated that FEV1 above 65% of the norm
indicated the possibility of pulmonary complica−
tions. In the material of the present study, the
severe respiratory complications observed in
group III corresponded to preoperatively
decreased results of spirometric examinations
(VC, FVC, FEV1, FEV1%VC, PEF). The differ−
ence was statistically significant in relation to the
findings in group I patients (p < 0.05). Group III
patients also revealed statistically significant (p <
0.05) decreases in pO2 and increases in pCO2 prior
to the surgery in comparison with patients without
pulmonary complications (group I). On the other
hand, the mean findings of other preoperative tests
(Hb, leukocyte and lymphocyte count, total serum
protein concentration) were within the norm and
did not show any statistically significant differ−
ences in either of the groups. Various degrees of
malnutrition in the preoperative period were found
in 31.3% of the patients and no statistical differ−
ences were found between the study groups.
The examinations on successive postoperative
days revealed a statistically significant decrease
(p < 0.05) in total serum protein levels in group III
patients compared with group I patients.
Moreover, group III patients demonstrated a sig−
nificant decrease in lymphocyte count to mean
levels below 1000/mm3 which was observed as
long as seven days after the procedure and may be
considered an unfavorable prognostic factor.
Limiting preoperative diagnostic procedures
to the primary disease, which is the target of sur−
gical interventions, and neglecting severe condi−
tions of a more general character may contribute
to severe postsurgical complications which may
threaten the patient’s life. Identifying respiratory
complications is of utmost significance in patients
in whom thoracotomy is planned. Spirometric
evaluation, which enables the diagnosis of venti−
lation disturbances and their differentiation into
restrictive and obturative, is believed to be suffi−
cient for this purpose. The possibilities of improv−
ing pulmonary function in the preoperative period
in patients with restrictive disorders are low, as
pharmacotherapy
is
usually
ineffective.
Nevertheless, breathing exercises in the preopera−
Respiratory Complications After Esophagectomy
tive period always seem useful, as they may
improve the patient’s techniques of spontaneous
deep breathing, coughing up, and ventilation with
expiratory resistance. In case of obturative disor−
ders, individually tailored preoperative physio−
therapy and pharmacotherapy may significantly
improve the respiratory activities.
825
In the face of a malignant, evidently life−
threatening disease, it is difficult to define general
systemic contraindications for surgical treatment;
however, it should be stressed that preoperative
evaluation of the risk factors may affect the choice
of the optimal time and modality of the operation
and determine the postoperative management of
the patient.
Acknowledgments. The authors thank Maria Zagrodnik of the Medical University Language Department for linguistic assistance.
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826
M. STRUTYŃSKA−KARPIŃSKA et al.
Address for correspondence:
Marta Strutyńska−Karpińska
Department and Clinic of Gastrointestinal and General Surgery,
Silesian Piasts University of Medicine
ul. Traugutta 57/59
50−417 Wrocław
Poland
Conflict of interest: None declared
Received: 21.04.2006
Revised: 12.07.2006
Accepted: 21.09.2006
Praca wpłynęła do Redakcji: 21.04.2006 r.
Po recenzji: 12.07.2006 r.
Zaakceptowano do druku: 21.09.2006 r.