📘 High-yield question on Chylothorax management after Esophagectomy.
Q) A 66-year-old male undergoes TTE. After esophagectomy, ICD output is 1000 ml chyle on 5th postoperative day. What should be the next step in management?
Q) After Ivor Lewis esophagectomy, on postoperative day 5 (POD 5), bile is seen in the chest tube.
The patient presents with a heart rate of 120 bpm, a temperature of 101°F, and blood pressure of 100/70 mmHg. What is the next appropriate step in management?
a) Stenting
b) Colonic replacement of gastric conduit
c) IV antibiotics
d) Conduit excision and esophageal diversion
Correct Answer: d) Conduit excision and esophageal diversion
In patients who develop a completely necrotic conduit post-esophagectomy, the risk of sepsis is high. These patients often require urgent surgical intervention. Upon confirming conduit necrosis, the conduit must be resected, and the patient should undergo diversion, which includes:
End esophagostomy
Venting gastrostomy
Feeding jejunostomy
It is crucial to maintain as much length of the remaining esophagus as possible to facilitate future reconstructive procedures.
Key Points:
Postoperative Day 5: Critical time for monitoring complications after esophagectomy.
Symptoms of Concern: Tachycardia, fever, and hypotension may indicate sepsis or other complications.
Surgical Intervention: Timely recognition and management are vital for patient outcomes.
For further reading, refer to Schakelford’s Surgical Anatomy of the Gastrointestinal Tract, 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
Answer: c
Pulmonary complications are 57% with TTE and 27% with THE (SKF 409).
Anastomotic leak: 16% in TTE vs 14% in THE (not significant).
Subclinical leak is slightly more in THE.
Option D is correct — THE can be done via minimally invasive approach.
Blackmon et al. published a propensity-matched analysis comparing outcomes between side-to-side stapled, end-to-end circular stapled, and handsewn — with no significant difference in leak rates. (SKF page 475)
Cardiac complications, Vocal cord palsy, Wound infection, Chyle leak are all more with TTE.