1. No category

Postoperative
Esophagectomy Pathways
Mike Pienta, Shari Barnett, Shannon Ranella, Rishindra Reddy, Philip Carrott, Bill Lynch, Andrew Chang, Mark Orringer, Jules Lin
Section of Thoracic Surgery
University of Michigan
Disclosures
I have no financial disclosures.
Esophagectomy
 High morbidity and mortality
 Comorbidities
 Malnourished due to dysphagia
 Technically complex
 Surgical field included abdomen, chest, and neck
 Ochsner and DeBakey reported 72% postoperative mortality in 191 patients 1941
TEFvater.org/esophageal/historyofesophagealreplacement.html
•
Transhiatal Esophagectomy
 Over 3000 performed at the University of Michigan
 Comparing 1976‐1998 vs 1998‐2006 (p<0.001)
 In hospital mortality decreased 4% to 1%
 Discharge within 10 days 52% vs 78%
Orringer MB, et al. Annals of Surgery 246: 363‐374, 2007
Outline
 Patient Selection
 Preoperative Preparation
 Intraoperative Management
 Postoperative Management
 Early Recognition and Treatment of Complications
Patient Selection






Cardiac disease
Pulmonary function
Activity level
Nutrition
Age
Risk Factors
http://www.joe‐ks.com
Preoperative Preparation




“Prehabilitation”
Ambulation 1‐3 miles/day
IS teaching and taken home
Preoperative teaching, Esophagectomy support group, and video
 Neoadjuvant Therapy – wait until patients return to baseline function
http://healthpages.org
Preoperative Factors
• Malnutrition (80% have some degree )
• Radiation
• Vascular disease
• Previous upper abdominal surgery
• Gastric ulcer disease
www.uofmhealth.org
Preoperative Preparation
 Smoking cessation 4 weeks
 Nutrition, Dobhoff if needed
 Dental hygiene
www.teethpictures.org
Intraoperative Management
 Communicate with Anesthesia
• Optimize fluid management
• Minimize hypotension
• Early extubation
 Careful technique
 No metal on the recurrent nerve
Conduit Ischemia
• No clear way to reverse ischemia
• Prevention key
• Gastric conduit relatively ischemic Liebermann‐Meffert DM, et al. Ann Thorac Surg. 1992; 54: 1110‐5
Perfusion Gastric Conduit
• Cranial 20% based on microscopic network of capillaries • 50% drop oxygen tension of fundus after intraabdominal mobilization
• Direct correlation fundus oximetry and anastomotic complications
Liebermann‐Meffert DM, et al. Ann Thorac Surg. 1992; 54: 1110‐5
Perfusion Gastric Conduit
• Ischemic preconditioning with laparoscopic division or embolization of left gastric 2‐3 weeks preoperatively
• No definitive benefit in human trials on outcomes
• Pharmacologic agents –
PGE1, bupivacaine epidural
• Improve early blood flow with no benefit viability or leak rate
Liebermann‐Meffert DM, et al. Ann Thorac Surg. 1992; 54: 1110‐5
Intraoperative Factors
• Protect right gastroepiploic artery
• Don’t make conduit too narrow
• Preserve fundus
• Avoid hypotension
• Adequate tunnel and hiatus – avoid venous congestion • Don’t traumatize the conduit
• Keep anastomosis away from gastric staple line
Intraoperative Management
 Standardized procedure and equipment
 Team approach
Pain Control ‐Epidural
 Decreased morbidity, mortality, and costs
 Decrease in pulmonary complications
 Allows early extubation
 Blocks efferent sympathetic outflow
http://www.treatingpain.com
Pain Control
 May reduce myocardial demand and decrease atrial fibrillation  May increase mesenteric venodilation with enhanced perfusion of gastric conduit
http://www.treatingpain.com
Postoperative Management
 Critical Pathway
 Physician‐directed
 Aid physicians, PA’s, residents, and nurses to provide consistent care
 Shown improve quality, decrease LOS http://www.medscape.org/
Critical Pathway – Day 0
Critical Pathway – Day 1
Critical Pathway – Day 2
Critical Pathway – Day 3
Critical Pathway – Day 4
Critical Pathway – Day 5
Critical Pathway – Day 6
Critical Pathway – Day 7
Toonpool.com
Avoiding ICU
 Only 4% required ICU stay
 Prevent common complications
 Recognize and treat postoperative issues early
wales.nhs.uk
Pneumonia
 Significant source of morbidity and mortality
 Associated advanced age, smoking, malnutrition, decreased pulmonary function
 Heitmller found airway protection diminished in 47‐67%
Orringer MB, et al. Annals of Surgery 246: 363‐374, 2007; Heitmiller RF, et al. Am J Surg. 162: 442‐6, 1991; medkast.libsyn.com
Pneumonia
 Recurrent nerve palsy (< 1% incidence, consider early medialization)
 Semi‐upright positioning (> 30 degrees) decreases aspiration by 18% (Drakulovic, et al)
 Replace NG tube if nausea
 Place NG if needs general anesthesia
 Avoid IPPB/BIPAP
Drakulovic MB, et al. Lancet. 354: 1851‐8, 1999; medkast.libsyn.com
Hypotension
• Avoid hypotension; Can contribute to anastomotic complications
• Hold epidural if needed to keep MAP > 60 • Bleeding • Prevent/treat afib
• Avoid gastric distension
Cooke DT, et al. Ann Thorac Surg. 2009; 88: 177‐85; EKGwatch.com
Postoperative Care Pathways
Using standardized techniques and critical care pathways have led to improvements in‐hospital mortality, anastomotic leak rate, and LOS avoiding the ICU in the majority of patients.
Preventing Complications
•
•
•
•
•
Patient Selection
Patient Selection
Preoperative Preparation
Preoperative Preparation
Intraoperative Management
Intraoperative Management
Postoperative Management
Postoperative Management
Early Recognition and Early Recognition and Treatment of Complications
Treatment of Complications
Ghaferi AA, et al. Annals of Surgery. 2009; 250: 1029‐1034
“Failure to Rescue”
• High volume centers/ surgeons better outcomes
• Not only preventing complications
• Ability recognize and treat complications
Ghaferi AA, et al. Annals of Surgery. 2009; 250: 1029‐1034
Diagnosis
• Early identification critical
• Up to 55% asymptomatic initially
• Standardized pathways reduce length of stay, costs, mortality www.lifescriptdoctor.com
Complication Pathways
• Preliminary group including a resident, PA, and an attending
• Chose 4 complications to focus on:
–
–
–
–
Atrial fibrillation
Anastomotic Leak
Dysphagia
Chylothorax
red7salon.com
Complication Pathways
• Surveys of entire team
• Most believed one common practice was followed
• Diagnosis and treatment plans varied significantly
• Complication Pathways
• Developed with input of all team members
www.westchestervillagehoa.com
Pathway Development Process
Convene Team
• ‘Burning Platform’ Data—Why is this project important?
• Complications and Failure to Rescue
• A3 to identify primary aims and measures of success
Survey Providers
• Review current care/treatment ‐ Do we have a standard of care that is followed across the team?
• When/How are complications identified?
• How quickly are treatments initiated?
Develop Pathway
• MD‐led, with resident, PA
• Develop first draft of pathways for most frequent complications with highest morbidity and mortality – IMPORTANT: Must have clinician consensus and stakeholder agreement
Develop Pilot
Modify Pathway
• Train other clinicians to use pathway(s)
• Develop database, identify resource and establish logistics for data collection and analysis
• Set start date and initiate pilot
• Develop plan to routinely review data
• Modify pathway(s) as indicated
• Review measures of success
Anastomotic Leak
• Potentially life‐threatening
• Mortality with complete necrosis as high as 50‐90%
• Leak must be recognized early and drained • If not treated aggressively risk of ongoing sepsis, bronchogastric or aortoenteric fistula, death
Anastomotic Leak
 Occurs average POD 7
 Fevers, erythema, crepitus, halitosis, drainage
 Between group I and II significant decrease 14% vs 9%
 Use of side‐to‐side stapled CEGA (p < 0.001) since 1997
 Minimize gastric trauma “pink in the abdomen – pink in the neck”
 Adequate mediastinal tunnel
Orringer MB, et al. Annals of Surgery 246: 363‐374, 2007; Cooke DT, et al. Ann Thorac Surg 88: 177‐85, 2009
Orringer MB, et al. J Thorac Cardiovasc Surg 119: 277‐88, 2000
Anastomotic Leak
 94% treated by wound packing
 Drink water during dressing changes to irrigate wound
 Early dilation (30, 36, 46 Fr) within 7‐10 days positive effect on closure of fistula
 1/3 of patients develop a stricture
Orringer MB, et al. Annals of Surgery 246: 363‐374, 2007; Cooke DT, et al. Ann Thorac
Surg 88: 177‐85, 2009
Chang AC and Orringer MB. Semin
Thorac Cardiovasc Surg 19: 66‐71, 2007
Severe Complications CEGA
 Uncommon
 1.3% severe cervical infections
 2 epidural abscesses, 1 vertebral osteomyelitis, 2 IJ abscesses
 1 tracheoesophagogastric fistula
 8/11 survived to discharge
 Gastric suspension stitch used early in the series
 All but minute leaks should be drained Iannettoni MD, et al. J Thorac Cardiovasc Surg 110: 1493‐1501, 1995
Gastric Conduit Necrosis
• Gastric tip necrosis with takedown of conduit and esophagostomy in 0.7‐2%
• 3 patients hypotension, 1 on steroids
• 1 previously divided right gastroepiploic but thought to be viable in OR
• Fever despite opening the neck, hypotension
• Endoscopy, consider chest CT
• 3 of 4 patients eventual reconstruction
Iannettoni MD, et al. J Thorac Cardiovasc Surg 110: 1493‐1501, 1995
Spectrum of Anastomotic Leak
• Grade I – No or Contained Leak
• Grade II – Clinical Minor Cervical Leak
• Grade III – Clinical Major Mediastinal/Pleural Leakage
• Grade IV ‐ Conduit Necrosis
Lerut T, et al. Dig Surg. 2002; 19: 92‐8
Anastomotic Leak
(II)
A
Crepitus and/or Cervical Drainage?
No
Yes
B
Halitosis and Erythema?
No
Start Peridex
Teach BID Wet‐to‐Dry Dressing Changes
Esophageal Dilation Within 48 h (to 46 or 51 Fr)
Serial CBC, Cultures
Barium Swallow
(II)
Go to B, if extends to mediastinum Go to D
Reassess Daily (A)
Definite Leak
(II)
Outpouching of Contrast
Go to B
Persistent fevers and leukocytosis
(I)
Contained trickle of Contrast
Go to C
D
Antibiotics & follow‐up Barium Swallow in 3 days
If tolerated for 24 h, advance to soft diet (otherwise NPO) with tube feeds
If persistent fevers, leukocytosis, or acidosis get chest +/‐ abd CT
If undrained collection or acidotic then go to D
(III)
Reassess Daily (A)
Confirmed Leak
Barium Swallow
POD 7
Go to C
C
Drink Water to Rinse Wound with Dressings
No
Yes
Yes
Open Neck
Clear Liquids
Fevers and Leukocytosis?
OR for Cervical Exploration & Drainage
EGD to look for extent of necrosis + Dilation 51 Fr
(III)
(IV)
If collection below carina or if effusion
If extensive conduit necrosis
Open or VATS decortication
Takedown and debride conduit, esophagostomy
Antibiotics, Antifungals; Outpatient Empyema Tube Management
ICU management for sepsis
Go to B
No Leak
Anastomotic Leak
(II)
A
Crepitus and/or Cervical Drainage?
No
Yes
B
Halitosis and Erythema?
No
Start Peridex
Teach BID Wet‐to‐Dry Dressing Changes
Esophageal Dilation Within 48 h (to 46 or 51 Fr)
Serial CBC, Cultures
Barium Swallow
(II)
Go to B, if extends to mediastinum Go to D
Reassess Daily (A)
Definite Leak
(II)
Outpouching of Contrast
Go to B
Persistent fevers and leukocytosis
(I)
Contained trickle of Contrast
Go to C
D
Antibiotics & follow‐up Barium Swallow in 3 days
If tolerated for 24 h, advance to soft diet (otherwise NPO) with tube feeds
If persistent fevers, leukocytosis, or acidosis get chest +/‐ abd CT
If undrained collection or acidotic then go to D
(III)
Reassess Daily (A)
Confirmed Leak
Barium Swallow
POD 7
Go to C
C
Drink Water to Rinse Wound with Dressings
No
Yes
Yes
Open Neck
Clear Liquids
Fevers and Leukocytosis?
OR for Cervical Exploration & Drainage
EGD to look for extent of necrosis + Dilation 51 Fr
(III)
(IV)
If collection below carina or if effusion
If extensive conduit necrosis
Open or VATS decortication
Takedown and debride conduit, esophagostomy
Antibiotics, Antifungals; Outpatient Empyema Tube Management
ICU management for sepsis
Go to B
No Leak
Anastomotic Leak
(II)
A
Crepitus and/or Cervical Drainage?
No
Yes
B
Halitosis and Erythema?
No
Start Peridex
Teach BID Wet‐to‐Dry Dressing Changes
Esophageal Dilation Within 48 h (to 46 or 51 Fr)
Serial CBC, Cultures
Barium Swallow
(II)
Go to B, if extends to mediastinum Go to D
Reassess Daily (A)
Definite Leak
(II)
Outpouching of Contrast
Go to B
Persistent fevers and leukocytosis
(I)
Contained trickle of Contrast
Go to C
D
Antibiotics & follow‐up Barium Swallow in 3 days
If tolerated for 24 h, advance to soft diet (otherwise NPO) with tube feeds
If persistent fevers, leukocytosis, or acidosis get chest +/‐ abd CT
If undrained collection or acidotic then go to D
(III)
Reassess Daily (A)
Confirmed Leak
Barium Swallow
POD 7
Go to C
C
Drink Water to Rinse Wound with Dressings
No
Yes
Yes
Open Neck
Clear Liquids
Fevers and Leukocytosis?
OR for Cervical Exploration & Drainage
EGD to look for extent of necrosis + Dilation 51 Fr
(III)
(IV)
If collection below carina or if effusion
If extensive conduit necrosis
Open or VATS decortication
Takedown and debride conduit, esophagostomy
Antibiotics, Antifungals; Outpatient Empyema Tube Management
ICU management for sepsis
Go to B
No Leak
Diagnosis
• Diagnostic Studies
– Esophagram
– Esophagoscopy
– Chest CT Clear Liquids
If tolerated for 24 h, advance to soft diet (otherwise NPO) with tube feeds
If persistent fevers, leukocytosis, or acidosis get chest +/‐ abd CT
If undrained collection or acidotic then go to D
C
Barium Swallow
(II)
Definite Leak
(II)
Outpouching of Contrast
(I)
Contained trickle of Contrast
(III)
EGD to look for extent of necrosis + Dilation 51 Fr
(IV)
If collection below carina or if effusion
If extensive conduit necrosis
Open or VATS decortication
Takedown and debride conduit, esophagostomy
Antibiotics, Antifungals; Outpatient Empyema Tube Management
ICU management for sepsis
Grade I
• Mucosal sloughing
• No or Contained Leak (Drains back into conduit)
Anastomotic Leak
(II)
A
Crepitus and/or Cervical Drainage?
No
Yes
B
Halitosis and Erythema?
No
Start Peridex
Teach BID Wet‐to‐Dry Dressing Changes
Esophageal Dilation Within 48 h (to 46 or 51 Fr)
Serial CBC, Cultures
Barium Swallow
(II)
Go to B, if extends to mediastinum Go to D
Reassess Daily (A)
Definite Leak
(II)
Outpouching of Contrast
Go to B
Persistent fevers and leukocytosis
(I)
Contained trickle of Contrast
Go to C
D
Antibiotics & follow‐up Barium Swallow in 3 days
If tolerated for 24 h, advance to soft diet (otherwise NPO) with tube feeds
If persistent fevers, leukocytosis, or acidosis get chest +/‐ abd CT
If undrained collection or acidotic then go to D
(III)
Reassess Daily (A)
Confirmed Leak
Barium Swallow
POD 7
Go to C
C
Drink Water to Rinse Wound with Dressings
No
Yes
Yes
Open Neck
Clear Liquids
Fevers and Leukocytosis?
OR for Cervical Exploration & Drainage
EGD to look for extent of necrosis + Dilation 51 Fr
(III)
(IV)
If collection below carina or if effusion
If extensive conduit necrosis
Open or VATS decortication
Takedown and debride conduit, esophagostomy
Antibiotics, Antifungals; Outpatient Empyema Tube Management
ICU management for sepsis
Go to B
No Leak
Treatment – Grade I
• Antibiotics, barium swallow in 3 days
• Open cervical incision if redness or fevers
(I)
Contained trickle of Contrast
Antibiotics & follow‐up Barium Swallow in 3 days
Reassess Daily (A)
Confirmed Leak
No Leak
Grade II
• Localized anastomotic necrosis
• Cervical leak clinically or on esophagram
Anastomotic Leak
(II)
A
Crepitus and/or Cervical Drainage?
No
Yes
B
Halitosis and Erythema?
No
Start Peridex
Teach BID Wet‐to‐Dry Dressing Changes
Esophageal Dilation Within 48 h (to 46 or 51 Fr)
Serial CBC, Cultures
Barium Swallow
(II)
Go to B, if extends to mediastinum Go to D
Reassess Daily (A)
Definite Leak
(II)
Outpouching of Contrast
Go to B
Persistent fevers and leukocytosis
(I)
Contained trickle of Contrast
Go to C
D
Antibiotics & follow‐up Barium Swallow in 3 days
If tolerated for 24 h, advance to soft diet (otherwise NPO) with tube feeds
If persistent fevers, leukocytosis, or acidosis get chest +/‐ abd CT
If undrained collection or acidotic then go to D
(III)
Reassess Daily (A)
Confirmed Leak
Barium Swallow
POD 7
Go to C
C
Drink Water to Rinse Wound with Dressings
No
Yes
Yes
Open Neck
Clear Liquids
Fevers and Leukocytosis?
OR for Cervical Exploration & Drainage
EGD to look for extent of necrosis + Dilation 51 Fr
(III)
(IV)
If collection below carina or if effusion
If extensive conduit necrosis
Open or VATS decortication
Takedown and debride conduit, esophagostomy
Antibiotics, Antifungals; Outpatient Empyema Tube Management
ICU management for sepsis
Go to B
No Leak
Anastomotic Leak
(II)
A
Crepitus and/or Cervical Drainage?
No
Yes
B
Halitosis and Erythema?
No
Start Peridex
Teach BID Wet‐to‐Dry Dressing Changes
Esophageal Dilation Within 48 h (to 46 or 51 Fr)
Serial CBC, Cultures
Barium Swallow
(II)
Go to B, if extends to mediastinum Go to D
Reassess Daily (A)
Definite Leak
(II)
Outpouching of Contrast
Go to B
Persistent fevers and leukocytosis
(I)
Contained trickle of Contrast
Go to C
D
Antibiotics & follow‐up Barium Swallow in 3 days
If tolerated for 24 h, advance to soft diet (otherwise NPO) with tube feeds
If persistent fevers, leukocytosis, or acidosis get chest +/‐ abd CT
If undrained collection or acidotic then go to D
(III)
Reassess Daily (A)
Confirmed Leak
Barium Swallow
POD 7
Go to C
C
Drink Water to Rinse Wound with Dressings
No
Yes
Yes
Open Neck
Clear Liquids
Fevers and Leukocytosis?
OR for Cervical Exploration & Drainage
EGD to look for extent of necrosis + Dilation 51 Fr
(III)
(IV)
If collection below carina or if effusion
If extensive conduit necrosis
Open or VATS decortication
Takedown and debride conduit, esophagostomy
Antibiotics, Antifungals; Outpatient Empyema Tube Management
ICU management for sepsis
Go to B
No Leak
Treatment – Grade II
(II)
A
• Open cervical incision at bedside
• Early dilation to help with healing and decrease strictures
Crepitus and/or Cervical Drainage?
Yes
B
Open Neck
Teach BID Wet‐to‐Dry Dressing Changes
Drink Water to Rinse Wound with Dressings
Esophageal Dilation Within 48 h (to 46 or 51 Fr)
Clear Liquids
If tolerated for 24 h, advance to soft diet (otherwise NPO) with tube feeds
Treatment – Grade II
(II)
A
• If persistent fevers, hypotension, or chest pain :
• Exploration in OR ensure adequate drainage
• Esophagoscopy evaluate for conduit necrosis
• Chest CT evaluate for undrained collection
Crepitus and/or Cervical Drainage?
Yes
B
Open Neck
Teach BID Wet‐to‐Dry Dressing Changes
Drink Water to Rinse Wound with Dressings
Esophageal Dilation Within 48 h (to 46 or 51 Fr)
Clear Liquids
If tolerated for 24 h, advance to soft diet (otherwise NPO) with tube feeds
Grade II
Grade III
• Anastomotic or gastric tip necrosis with remainder of stomach viable
• Mediastinal and pleural leakage Grade III
Anastomotic Leak
(II)
A
Crepitus and/or Cervical Drainage?
No
Yes
B
Halitosis and Erythema?
No
Start Peridex
Teach BID Wet‐to‐Dry Dressing Changes
Esophageal Dilation Within 48 h (to 46 or 51 Fr)
Serial CBC, Cultures
Barium Swallow
(II)
Go to B, if extends to mediastinum Go to D
Reassess Daily (A)
Definite Leak
(II)
Outpouching of Contrast
Go to B
Persistent fevers and leukocytosis
(I)
Contained trickle of Contrast
Go to C
D
Antibiotics & follow‐up Barium Swallow in 3 days
If tolerated for 24 h, advance to soft diet (otherwise NPO) with tube feeds
If persistent fevers, leukocytosis, or acidosis get chest +/‐ abd CT
If undrained collection or acidotic then go to D
(III)
Reassess Daily (A)
Confirmed Leak
Barium Swallow
POD 7
Go to C
C
Drink Water to Rinse Wound with Dressings
No
Yes
Yes
Open Neck
Clear Liquids
Fevers and Leukocytosis?
OR for Cervical Exploration & Drainage
EGD to look for extent of necrosis + Dilation 51 Fr
(III)
(IV)
If collection below carina or if effusion
If extensive conduit necrosis
Open or VATS decortication
Takedown and debride conduit, esophagostomy
Antibiotics, Antifungals; Outpatient Empyema Tube Management
ICU management for sepsis
Go to B
No Leak
Anastomotic Leak
(II)
A
Crepitus and/or Cervical Drainage?
No
Yes
B
Halitosis and Erythema?
No
Start Peridex
Teach BID Wet‐to‐Dry Dressing Changes
Esophageal Dilation Within 48 h (to 46 or 51 Fr)
Serial CBC, Cultures
Barium Swallow
(II)
Go to B, if extends to mediastinum Go to D
Reassess Daily (A)
Definite Leak
(II)
Outpouching of Contrast
Go to B
Persistent fevers and leukocytosis
(I)
Contained trickle of Contrast
Go to C
D
Antibiotics & follow‐up Barium Swallow in 3 days
If tolerated for 24 h, advance to soft diet (otherwise NPO) with tube feeds
If persistent fevers, leukocytosis, or acidosis get chest +/‐ abd CT
If undrained collection or acidotic then go to D
(III)
Reassess Daily (A)
Confirmed Leak
Barium Swallow
POD 7
Go to C
C
Drink Water to Rinse Wound with Dressings
No
Yes
Yes
Open Neck
Clear Liquids
Fevers and Leukocytosis?
OR for Cervical Exploration & Drainage
EGD to look for extent of necrosis + Dilation 51 Fr
(III)
(IV)
If collection below carina or if effusion
If extensive conduit necrosis
Open or VATS decortication
Takedown and debride conduit, esophagostomy
Antibiotics, Antifungals; Outpatient Empyema Tube Management
ICU management for sepsis
Go to B
No Leak
Treatment – Grade III
• Open cervical incision
• Mediastinal abscess up to carina ‐ Irrigation using Red Robinson catheter
• Mediastinal abscess below carina or intrapleural ‐ VATS or open decortication
• Dilation
• NPO; J‐tube feedings
• Antibiotics, antifungals
D
(III)
OR for Cervical Exploration & Drainage
EGD to look for extent of necrosis + Dilation 51 Fr
If collection below carina or if effusion
Open or VATS decortication
Antibiotics, Antifungals; Outpatient Empyema Tube Management
(III)
Grade III
Grade IV
• Necrosis of gastric conduit
• Incidence 0.7 to 5.1%
• Traditionally mortality 90%
• Minimally invasive esophagectomy ‐ 3.2% incidence
• May be increased with narrow conduits
Anastomotic Leak
(II)
A
Crepitus and/or Cervical Drainage?
No
Yes
B
Halitosis and Erythema?
No
Start Peridex
Teach BID Wet‐to‐Dry Dressing Changes
Esophageal Dilation Within 48 h (to 46 or 51 Fr)
Serial CBC, Cultures
Barium Swallow
(II)
Go to B, if extends to mediastinum Go to D
Reassess Daily (A)
Definite Leak
(II)
Outpouching of Contrast
Go to B
Persistent fevers and leukocytosis
(I)
Contained trickle of Contrast
Go to C
D
Antibiotics & follow‐up Barium Swallow in 3 days
If tolerated for 24 h, advance to soft diet (otherwise NPO) with tube feeds
If persistent fevers, leukocytosis, or acidosis get chest +/‐ abd CT
If undrained collection or acidotic then go to D
(III)
Reassess Daily (A)
Confirmed Leak
Barium Swallow
POD 7
Go to C
C
Drink Water to Rinse Wound with Dressings
No
Yes
Yes
Open Neck
Clear Liquids
Fevers and Leukocytosis?
OR for Cervical Exploration & Drainage
EGD to look for extent of necrosis + Dilation 51 Fr
(III)
(IV)
If collection below carina or if effusion
If extensive conduit necrosis
Open or VATS decortication
Takedown and debride conduit, esophagostomy
Antibiotics, Antifungals; Outpatient Empyema Tube Management
ICU management for sepsis
Go to B
No Leak
Anastomotic Leak
(II)
A
Crepitus and/or Cervical Drainage?
No
Yes
B
Halitosis and Erythema?
No
Start Peridex
Teach BID Wet‐to‐Dry Dressing Changes
Esophageal Dilation Within 48 h (to 46 or 51 Fr)
Serial CBC, Cultures
Barium Swallow
(II)
Go to B, if extends to mediastinum Go to D
Reassess Daily (A)
Definite Leak
(II)
Outpouching of Contrast
Go to B
Persistent fevers and leukocytosis
(I)
Contained trickle of Contrast
Go to C
D
Antibiotics & follow‐up Barium Swallow in 3 days
If tolerated for 24 h, advance to soft diet (otherwise NPO) with tube feeds
If persistent fevers, leukocytosis, or acidosis get chest +/‐ abd CT
If undrained collection or acidotic then go to D
(III)
Reassess Daily (A)
Confirmed Leak
Barium Swallow
POD 7
Go to C
C
Drink Water to Rinse Wound with Dressings
No
Yes
Yes
Open Neck
Clear Liquids
Fevers and Leukocytosis?
OR for Cervical Exploration & Drainage
EGD to look for extent of necrosis + Dilation 51 Fr
(III)
(IV)
If collection below carina or if effusion
If extensive conduit necrosis
Open or VATS decortication
Takedown and debride conduit, esophagostomy
Antibiotics, Antifungals; Outpatient Empyema Tube Management
ICU management for sepsis
Go to B
No Leak
Treatment – Grade IV
• Take down conduit and debride necrotic tissue/gastrectomy
• Mediastinal irrigation
• Chest tubes • Esophagostomy
• ICU; Treatment for sepsis
Orringer MB in Greenfield LJ (ed). Complications in Surgery and Trauma, 2nd Ed
(IV)
If extensive conduit necrosis
Takedown and debride conduit, esophagostomy
ICU management for sepsis
Outpatient Care
• Localized leak
– Cervical dressing changes
– J‐tube feedings
– When drainage is low –
soft diet
– Dilation as needed
• Mediastinal Abscess ‐
Gradually withdraw Penrose
Chang AC, et al. Semin Thorac Cardiovasc Surg. 2007; 19(1):66‐71
Outpatient Care
• Pleural Drainage ‐
Gradually withdraw chest tubes
• Esophagostomy
– Dilate digitally
– Retrosternal colon interposition if no cancer recurrence (6‐
12 months)
Atrial Fibrillation
 6.6% in our series
 First 4 postoperative days
 Associated with pulmonary complications, anastomotic leak
 Contributing factors:
 Hypervolemia
 Mediastinal inflammation
 Electrolyte shifts
 Increased sympathetic tone
 Beta blockers, amiodarone
Cooke DT, et al. Ann Thorac Surg 88: 177‐85, 2009;EKGwatch.com
Atrial Fibrillation
Atrial Fibrillation
New onset atrial fibrillation
postoperatively
SBP<100
A
No
Unstable?
SBP>100
Yes
Chemical cardioversion
Yes
Symptomatically Intolerable*?
No
If no severe COPD or severe lung disease,
Amiodarone 150 mg IV **
Electrical cardioversion
Conversion?
Yes
Convert to Amiodarone 0.5 mg/min IV (PICC) or 400 mg daily PO/ per J tube
Yes
Go to B
Metoprolol 5 mg IV bolus, repeat as needed x 2 every 20 minutes
Flecainide 200mg PO (300 mg if > 70 kg) **
No
only if severe lung disease and
***
no heart disease
PICC line placement PLUS Diltiazem 10 mg IV or 120 mg PO†
Amiodarone bolus 150 mg Then Flecainide 50 mg IV x 2 every 20 min PO Q 12 hrs
If severe COPD, use Diltiazem 10 mg bolus then 10‐20 mg/hr drip for up to 6 hours
If becomes symptomatically intolerable* Go to A
Conversion?
No
Amiodarone drip 1 mg/min x 6 hrs then 0.5 mg/min x 18 hrs
No
Conversion?
Yes
Yes
No
Persistent or recurrent afib, >24hrs
* Severe palpita ons, chest pain, SOB, ↓BP
** Cardiology consult if severe lung and heart disease
*** LVH, RVH, systolic dysfunction (EF<40%), valvular (>/= moderate), or CAD. No aflutter.
† Do not give dil azem if the pa ent has recently been given a beta or calcium channel blocker
Consult Cardiology re: cardioversion
Consider anticoagulation/ASA with Cardiology if > 48 h postop
Conversion to SR after metoprolol x 3 or diltiazem (up to 6 hrs)?
Once in SR and tolerating orals, transition to PO metoprolol or diltiazem for 3 weeks
Persistent or recurrent afib for >24hrs
B
Once in SR >24 hrs, discharge on antiarrhythmic for 3 weeks
Follow‐up with PCP or Cardiology
Atrial Fibrillation
New onset atrial fibrillation
postoperatively
SBP<100
SBP>100
A
No
Unstable?
Modified 9/15/13
Yes
Chemical cardioversion
Yes
Symptomatically Intolerable*?
No
If no severe COPD or severe lung disease,
Amiodarone 150 mg IV **
Electrical cardioversion
Conversion?
Yes
Convert to Amiodarone 0.5 mg/min IV (PICC) or 400 mg daily PO/ per J tube
Yes
Go to B
Metoprolol 5 mg IV bolus, repeat as needed x 2 every 20 minutes
Flecainide 200mg PO (300 mg if > 70 kg) **
No
only if severe lung disease and
***
no heart disease
PICC line placement PLUS Diltiazem 10 mg IV or 120 mg PO†
Amiodarone bolus 150 mg Then Flecainide 50 mg IV x 2 every 20 min PO Q 12 hrs
If severe COPD, use Diltiazem 10 mg bolus then 10‐20 mg/hr drip for up to 6 hours
If becomes symptomatically intolerable* Go to A
Conversion?
No
Amiodarone drip 1 mg/min x 6 hrs then 0.5 mg/min x 18 hrs
No
Conversion?
Yes
Yes
No
Persistent or recurrent afib, >24hrs
* Severe palpita ons, chest pain, SOB, ↓BP
** Cardiology consult if severe lung and heart disease
*** LVH, RVH, systolic dysfunction (EF<40%), valvular (>/= moderate), or CAD. No aflutter.
† Do not give dil azem if the pa ent has recently been given a beta or calcium channel blocker
Consult Cardiology re: cardioversion
Consider anticoagulation/ASA with Cardiology if > 48 h postop
Conversion to SR after metoprolol x 3 or diltiazem (up to 6 hrs)?
Once in SR and tolerating orals, transition to PO metoprolol or diltiazem for 3 weeks
Persistent or recurrent afib for >24hrs
B
Once in SR >24 hrs, discharge on antiarrhythmic for 3 weeks
Follow‐up with PCP or Cardiology
Atrial Fibrillation
New onset atrial fibrillation
postoperatively
SBP<100
SBP>100
A
No
Unstable?
Modified 9/15/13
Yes
Chemical cardioversion
Yes
Symptomatically Intolerable*?
No
If no severe COPD or severe lung disease,
Amiodarone 150 mg IV **
Electrical cardioversion
Conversion?
Yes
Convert to Amiodarone 0.5 mg/min IV (PICC) or 400 mg daily PO/ per J tube
Yes
Go to B
Metoprolol 5 mg IV bolus, repeat as needed x 2 every 20 minutes
Flecainide 200mg PO (300 mg if > 70 kg) **
No
only if severe lung disease and
***
no heart disease
PICC line placement PLUS Diltiazem 10 mg IV or 120 mg PO†
Amiodarone bolus 150 mg Then Flecainide 50 mg IV x 2 every 20 min PO Q 12 hrs
If severe COPD, use Diltiazem 10 mg bolus then 10‐20 mg/hr drip for up to 6 hours
If becomes symptomatically intolerable* Go to A
Conversion?
No
Amiodarone drip 1 mg/min x 6 hrs then 0.5 mg/min x 18 hrs
No
Conversion?
Yes
Yes
No
Persistent or recurrent afib, >24hrs
* Severe palpita ons, chest pain, SOB, ↓BP
** Cardiology consult if severe lung and heart disease
*** LVH, RVH, systolic dysfunction (EF<40%), valvular (>/= moderate), or CAD. No aflutter.
† Do not give dil azem if the pa ent has recently been given a beta or calcium channel blocker
Consult Cardiology re: cardioversion
Consider anticoagulation/ASA with Cardiology if > 48 h postop
Conversion to SR after metoprolol x 3 or diltiazem (up to 6 hrs)?
Once in SR and tolerating orals, transition to PO metoprolol or diltiazem for 3 weeks
Persistent or recurrent afib for >24hrs
B
Once in SR >24 hrs, discharge on antiarrhythmic for 3 weeks
Follow‐up with PCP or Cardiology
Atrial Fibrillation
New onset atrial fibrillation
postoperatively
SBP<100
SBP>100
A
No
Unstable?
Modified 9/15/13
Yes
Chemical cardioversion
Yes
Symptomatically Intolerable*?
No
If no severe COPD or severe lung disease,
Amiodarone 150 mg IV **
Electrical cardioversion
Conversion?
Yes
Convert to Amiodarone 0.5 mg/min IV (PICC) or 400 mg daily PO/ per J tube
Yes
Go to B
Metoprolol 5 mg IV bolus, repeat as needed x 2 every 20 minutes
Flecainide 200mg PO (300 mg if > 70 kg) **
No
only if severe lung disease and
***
no heart disease
PICC line placement PLUS Diltiazem 10 mg IV or 120 mg PO†
Amiodarone bolus 150 mg Then Flecainide 50 mg IV x 2 every 20 min PO Q 12 hrs
If severe COPD, use Diltiazem 10 mg bolus then 10‐20 mg/hr drip for up to 6 hours
If becomes symptomatically intolerable* Go to A
Conversion?
No
Amiodarone drip 1 mg/min x 6 hrs then 0.5 mg/min x 18 hrs
No
Conversion?
Yes
Yes
No
Persistent or recurrent afib, >24hrs
* Severe palpita ons, chest pain, SOB, ↓BP
** Cardiology consult if severe lung and heart disease
*** LVH, RVH, systolic dysfunction (EF<40%), valvular (>/= moderate), or CAD. No aflutter.
† Do not give dil azem if the pa ent has recently been given a beta or calcium channel blocker
Consult Cardiology re: cardioversion
Consider anticoagulation/ASA with Cardiology if > 48 h postop
Conversion to SR after metoprolol x 3 or diltiazem (up to 6 hrs)?
Once in SR and tolerating orals, transition to PO metoprolol or diltiazem for 3 weeks
Persistent or recurrent afib for >24hrs
B
Once in SR >24 hrs, discharge on antiarrhythmic for 3 weeks
Follow‐up with PCP or Cardiology
Anastomotic Stricture
• Low threshold to dilate
• Up to 40% of patients
• Dilation at bedside or in MPU
Chang AC, et al. Semin Thorac Cardiovasc Surg. 2007; 19(1):66‐71
Anastomotic Stricture
If dysphagia or leak, bedside dilation
prior to d/c home
(36‐40‐46 Fr)
No
Pt calls with dysphagia to solids or liquids
Can patient swallow liquids at all?
If not tolerated, MPU dilation to 51 Fr
Schedule clinic dilation
(36‐40‐46 Fr)
Recurrent Dysphagia
If not tolerated, MPU dilation to 51 Fr
Clinic (A) or MPU (B) based on dilation history, MPU if can’t tolerate liquids
Schedule clinic (A)/MPU (B) dilation within 1 wk, then every 2 weeks x 2 then prn
If dilations required < 2 week intervals x 2
Tolerates Clinic Dilation?
Yes
Teach pt self dilations
Send home with
44‐46 Fr dilator depending on resistance
Dilate daily x 1 wk,
QOD x 1 wk, then
Add 1 day per week until longest interval without dysphagia MPU dilation to 51 Fr
Yes
A
C
No
No
Scheduled MPU dilations every 1‐2 weeks x 3 , then prn
Consider Kenalog injection (1 mg)
Schedule clinic (A) dilation within 1 wk, then every 2 weeks x 2 then prn
Recurrent Dysphagia
Go to C
B
Anastomotic Stricture
If dysphagia or leak, bedside dilation
prior to d/c home
(36‐40‐46 Fr)
No
Pt calls with dysphagia to solids or liquids
Can patient swallow liquids at all?
If not tolerated, MPU dilation to 51 Fr
Schedule clinic dilation
(36‐40‐46 Fr)
Recurrent Dysphagia
If not tolerated, MPU dilation to 51 Fr
Clinic (A) or MPU (B) based on dilation history, MPU if can’t tolerate liquids
Schedule clinic (A)/MPU (B) dilation within 1 wk, then every 2 weeks x 2 then prn
If dilations required < 2 week intervals x 2
Tolerates Clinic Dilation?
Yes
Teach pt self dilations
Send home with
44‐46 Fr dilator depending on resistance
Dilate daily x 1 wk,
QOD x 1 wk, then
Add 1 day per week until longest interval without dysphagia MPU dilation to 51 Fr
Yes
A
C
No
No
Scheduled MPU dilations every 1‐2 weeks x 3 , then prn
Consider Kenalog injection (1 mg)
Schedule clinic (A) dilation within 1 wk, then every 2 weeks x 2 then prn
Recurrent Dysphagia
Go to C
B
Anastomotic Stricture
If dysphagia or leak, bedside dilation
prior to d/c home
(36‐40‐46 Fr)
No
Pt calls with dysphagia to solids or liquids
Can patient swallow liquids at all?
If not tolerated, MPU dilation to 51 Fr
Schedule clinic dilation
(36‐40‐46 Fr)
Recurrent Dysphagia
If not tolerated, MPU dilation to 51 Fr
Clinic (A) or MPU (B) based on dilation history, MPU if can’t tolerate liquids
Schedule clinic (A)/MPU (B) dilation within 1 wk, then every 2 weeks x 2 then prn
If dilations required < 2 week intervals x 2
Tolerates Clinic Dilation?
Yes
Teach pt self dilations
Send home with
44‐46 Fr dilator depending on resistance
Dilate daily x 1 wk,
QOD x 1 wk, then
Add 1 day per week until longest interval without dysphagia MPU dilation to 51 Fr
Yes
A
C
No
No
Scheduled MPU dilations every 1‐2 weeks x 3 , then prn
Consider Kenalog injection (1 mg)
Schedule clinic (A) dilation within 1 wk, then every 2 weeks x 2 then prn
Recurrent Dysphagia
Go to C
B
Anastomotic Stricture
If dysphagia or leak, bedside dilation
prior to d/c home
(36‐40‐46 Fr)
No
Pt calls with dysphagia to solids or liquids
Can patient swallow liquids at all?
If not tolerated, MPU dilation to 51 Fr
Schedule clinic dilation
(36‐40‐46 Fr)
Recurrent Dysphagia
If not tolerated, MPU dilation to 51 Fr
Clinic (A) or MPU (B) based on dilation history, MPU if can’t tolerate liquids
Schedule clinic (A)/MPU (B) dilation within 1 wk, then every 2 weeks x 2 then prn
If dilations required < 2 week intervals x 2
Tolerates Clinic Dilation?
Yes
Teach pt self dilations
Send home with
44‐46 Fr dilator depending on resistance
Dilate daily x 1 wk,
QOD x 1 wk, then
Add 1 day per week until longest interval without dysphagia MPU dilation to 51 Fr
Yes
A
C
No
No
Scheduled MPU dilations every 1‐2 weeks x 3 , then prn
Consider Kenalog injection (1 mg)
Schedule clinic (A) dilation within 1 wk, then every 2 weeks x 2 then prn
Recurrent Dysphagia
Go to C
B
Chylothorax




< 1% incidence latest series
High chest tube output > 72 hours
Loss albumin, protein, lymphocytes
Early recognition, aggressive treatment in nutritionally depleted patients
 Administer cream through J‐tube at least 6 hours
 Transthoracic duct ligation within 7‐10 days of resection
 No deaths, One recurrence
Orringer MB, et al. Surgery 104: 720‐6, 1988; strattonhouse.com
Chylothorax
</= 200cc/q8h CT output 3‐5 days after esophagectomy >/= 500cc/q8h
200‐500cc/q8h
Diet started*
Diet started*
Serous
Diet started*
Remove CT when
< 60cc/q8h x 2
A
Opaque
Cream challenge 60‐
90cc/h per NG or J‐tube
Increased Creaminess
Fluid analysis
TG<110 or chylomicrons ‐
Opaque
Go to B
Go to A
C
Equivocal B
Serous
Cream 60‐90 cc/h for 6 hours pre‐op per NG or J‐tube
TG>110 or chylomicrons +
Vivonex or no fat diet x 48 h
Not chylothorax
<60cc/
q8h x2
Book OR
>200 cc/
q8h Thoracic duct ligation
Go to C
Right Mass ligation if unable to identify leak
60‐200 cc/q8h Remove CT
d/c on no fat diet x 1 month
Consider octreotide 100 mcg SQ TID
Yes
Regular diet if no effusion on CXR
* Full liquids or Tube feeds
Give Depot Octreotide
If on TFs, use Vivonex
Improvement after 24h?
Start low fat diet POD1
No
Go to C
d/c on low fat diet x 1 month
Chylothorax
</= 200cc/q8h CT output 3‐5 days after esophagectomy >/= 500cc/q8h
200‐500cc/q8h
Diet started*
Diet started*
Serous
Diet started*
Remove CT when
< 60cc/q8h x 2
A
Opaque
Cream challenge 60‐
90cc/h per NG or J‐tube
Increased Creaminess
Fluid analysis
TG<110 or chylomicrons ‐
Opaque
Go to B
Go to A
C
Equivocal B
Serous
Cream 60‐90 cc/h for 6 hours pre‐op per NG or J‐tube
TG>110 or chylomicrons +
Vivonex or no fat diet x 48 h
Not chylothorax
<60cc/
q8h x2
Book OR
>200 cc/
q8h Thoracic duct ligation
Go to C
Right Mass ligation if unable to identify leak
60‐200 cc/q8h Remove CT
d/c on no fat diet x 1 month
Consider octreotide 100 mcg SQ TID
Yes
Regular diet if no effusion on CXR
* Full liquids or Tube feeds
Give Depot Octreotide
If on TFs, use Vivonex
Improvement after 24h?
Start low fat diet POD1
No
Go to C
d/c on low fat diet x 1 month
Chylothorax
</= 200cc/q8h CT output 3‐5 days after esophagectomy >/= 500cc/q8h
200‐500cc/q8h
Diet started*
Diet started*
Serous
Diet started*
Remove CT when
< 60cc/q8h x 2
A
Opaque
Cream challenge 60‐
90cc/h per NG or J‐tube
Increased Creaminess
Fluid analysis
TG<110 or chylomicrons ‐
Opaque
Go to B
Go to A
C
Equivocal B
Serous
Cream 60‐90 cc/h for 6 hours pre‐op per NG or J‐tube
TG>110 or chylomicrons +
Vivonex or no fat diet x 48 h
Not chylothorax
<60cc/
q8h x2
Book OR
>200 cc/
q8h Thoracic duct ligation
Go to C
Right Mass ligation if unable to identify leak
60‐200 cc/q8h Remove CT
d/c on no fat diet x 1 month
Consider octreotide 100 mcg SQ TID
Yes
Regular diet if no effusion on CXR
* Full liquids or Tube feeds
Give Depot Octreotide
If on TFs, use Vivonex
Improvement after 24h?
Start low fat diet POD1
No
Go to C
d/c on low fat diet x 1 month
Chylothorax
</= 200cc/q8h CT output 3‐5 days after esophagectomy >/= 500cc/q8h
200‐500cc/q8h
Diet started*
Diet started*
Serous
Diet started*
Remove CT when
< 60cc/q8h x 2
A
Opaque
Cream challenge 60‐
90cc/h per NG or J‐tube
Increased Creaminess
Fluid analysis
TG<110 or chylomicrons ‐
Opaque
Go to B
Go to A
C
Equivocal B
Serous
Cream 60‐90 cc/h for 6 hours pre‐op per NG or J‐tube
TG>110 or chylomicrons +
Vivonex or no fat diet x 48 h
Not chylothorax
<60cc/
q8h x2
Book OR
>200 cc/
q8h Thoracic duct ligation
Go to C
Right Mass ligation if unable to identify leak
60‐200 cc/q8h Remove CT
d/c on no fat diet x 1 month
Consider octreotide 100 mcg SQ TID
Yes
Regular diet if no effusion on CXR
* Full liquids or Tube feeds
Give Depot Octreotide
If on TFs, use Vivonex
Improvement after 24h?
Start low fat diet POD1
No
Go to C
d/c on low fat diet x 1 month
Chylothorax
</= 200cc/q8h CT output 3‐5 days after esophagectomy >/= 500cc/q8h
200‐500cc/q8h
Diet started*
Diet started*
Serous
Diet started*
Remove CT when
< 60cc/q8h x 2
A
Opaque
Cream challenge 60‐
90cc/h per NG or J‐tube
Increased Creaminess
Fluid analysis
TG<110 or chylomicrons ‐
Opaque
Go to B
Go to A
C
Equivocal B
Serous
Cream 60‐90 cc/h for 6 hours pre‐op per NG or J‐tube
TG>110 or chylomicrons +
Vivonex or no fat diet x 48 h
Not chylothorax
<60cc/
q8h x2
Book OR
>200 cc/
q8h Thoracic duct ligation
Go to C
Right Mass ligation if unable to identify leak
60‐200 cc/q8h Remove CT
d/c on no fat diet x 1 month
Consider octreotide 100 mcg SQ TID
Yes
Regular diet if no effusion on CXR
* Full liquids or Tube feeds
Give Depot Octreotide
If on TFs, use Vivonex
Improvement after 24h?
Start low fat diet POD1
No
Go to C
d/c on low fat diet x 1 month
Preliminary Data
• Complication Pathways implemented in Sept 2013
• Support of Surgical Services Value Stream Committee • With the help of Sam Clark from Program & Operations Analysis
• Developing system to continuously assess • Incidence rate
• Compliance with established pathways • Associated LOS for complications
Period
7/29/13 ‐ 7/7/14
Pts w/ Leak
27
Pts
Dilated
20
% Pts Dilated
74.1%
Pts Dilated Pre Discharge
10
% Dilated Pts Pre Discharge
50.0%
% Pts w/ Leak Dilated Pre Discharge
37.0%
Period
7/29/13 ‐ 7/7/14
Pts w/ Dysphagia
Dysphagia Pts
Dilated
% Dysphagia Pts Dilated
Dysphagia Pts Dilated Pre Discharge
21
21
100.0%
3
% Pts w/ % Dilated Pts Pre Dysphagia Dilated Discharge
Pre Discharge
14.3%
14.3%
Preliminary Data
Median
Avg
Min
Max
Sample Size
2
3.5
1
14
40
Dysphagia
Atrial Fibrillation
LOS by Complication Category
Complication
Median
Avg
Min
Max Sample size
Afib
Anastomotic Leak
10
10.0
7
17
10
14
16.1
7
71
27
Chylothorax
16
16.3
8
25
8
Dysphagia
8
9.0
7
17
21
LOS by Complication Category
Thoracic LOS and Readmissions
 Creating a new “culture” as a result of these complication pathways
 Overall LOS for all thoracic procedures decreased 14.1%
 Readmissions decreased 12.0%
Goals
 To improve outcomes in patients who develop complications in the post‐op period
 To increase awareness of complications following esophagectomy
 To streamline the detection and treatment of these complications to positively impact outcome:
 Decrease LOS
 Increase conversion to sinus rhythm
 Decrease time to diagnosis and treatment of anastomotic leak and chylothorax
 Increase the ability to eat after stricture
University of Michigan Esophagectomy Support Group