Complications, risks, and consequences
Estimated frequency
Most significant/serious complications
Injury to mouth, teeth, pharynx, or larynxa
1–5 %
Rare significant/serious problems
Bleeding/hematoma formationa
0.1–1 %
Perforationa
0.1–1 %
Infection
0.1–1 %
Failure to visualize parts of stomach or duodenuma
0.1–1 %
Failure to adequately biopsya
0.1–1 %
Aspiration pneumonitisa
0.1–1 %
Respiratory depressiona
<0.1 %
Less serious complications
Gas bloating (transient)
5–20 %
Discomfort, sore throat
5–20 %
Perspective
See Table 3.1. The risks and the incidence of complications of upper GI endoscopic procedures, even including multiple tissue biopsies, are very low. However, the patient should ideally be made aware of the few serious complications in the unlikely event that these should occur, because the consequences may be serious and even require open surgery. Minor consequences such as gas bloating are more of an inconvenience value for the patient; however, occasionally, these may be significant. Failure to adequately biopsy a lesion of note may occur and the patient should also be warned of this possibility and the need for a further procedure(s). The risks associated with therapeutic procedures are greater and include esophageal perforation associated with dilatation of strictures, stent insertion and perforation, and necrosis which can complicate the treatment of bleeding ulcers.
Major Complications
Although rare, the major complications of endoscopy are perforation of the esophagus, and less frequently of the stomach or duodenum. This can be serious, even if detected immediately, and can lead to mediastinitis and sepsis, organ failure, intensive care management, and death. If perforation is suspected a contrast study must be performed to define the site and size of perforation and the degree of contamination. Open surgery to repair the defect may be performed immediately after waking and discussion with the patient. Later detection carries a greater and more serious risk of adverse outcomes. Most instrumental perforations are small and managed conservatively. Open surgery is occasionally required to drain the area of contamination or to repair the defect. Delayed and unrecognized perforation carries a greater and more serious risk of adverse outcomes. Aspiration pneumonitis is less common in the partially awake and fasted patient. However, when it occurs it may be very serious and lead to ARDS and secondary infection causing lobar- or bronchopneumonia, sepsis, organ failure, intensive care support, and sometimes death. Aspiration pneumonitis is usually more serious after emergency endoscopy in the unprepared, unfasted patient, although less desirably and commonly performed in this group. Significant respiratory depression is a potentially serious complication of sedation and endoscopy and can lead to brain injury and even death, although now virtually abolished as a complication by good oximetric monitoring and anesthetic care during endoscopy. Failure to visualize or biopsy pathology may lead to failure to diagnose or more commonly repeat endoscopy +/− biopsy. Injury to teeth or the oral cavity is relatively rare if care is exercised, but major injury can still occur and may have major significance for the patient. Injury to the cervical spine is possible, but exceedingly rare.
Consent and Risk Reduction
Main Points to Explain
Discomfort and gas bloating
Injury to mouth and teeth
Bleeding
Problems with sedation
Failure to visualize parts of upper GI
Perforation
Infection
Further surgery; laparotomy
Esophageal Manometry
Description
Local anesthetic topical spray or gel is usually used. The aim is to pass a catheter with pressure censoring openings or a sleeve device through the esophagus into the stomach for measuring pressures in the body of the esophagus and lower esophageal sphincter region. The catheter is perfused with low volumes of water, and the patient is given 2 mL boluses of water to swallow at greater than 15-s intervals. Usually 5–10 “wet swallows” and a number of “dry swallows” are recorded. The procedure usually takes about 20 min.
Anatomical Points
The anatomy of the esophagus is relatively constant; however, the presence of pharyngeal or esophageal diverticula, webs, or an excessively short or long esophagus may cause technical difficulties. These may be evident on prior endoscopy, which is often performed.
Table 3.2
Esophageal manometry: estimated frequency of complications, risks, and consequences
Complications, risks, and consequences | Estimated frequency |
|---|---|
Most significant/serious complications | |
Discomfort | >80 % |
Dysphagia (transient)a | >80 % |
Nasal/pharyngeal trauma | |
Minor | 20–50 % |
Major | 0.1–1 % |
Dislodgementa | 1–5 % |
Rare significant/serious problems | |
Bleeding | 0.1–1 % |
Perforation | <0.1 % |
Aspiration pneumonitis | <0.1 % |
Less serious complications | |
Failure to detect reflux/abnormal motility when presenta | 0.1–1 % |
Perspective
See Table 3.2. Esophageal manometry is a relatively safe procedure used to diagnose patients with gastroesophageal reflux disease or motility disturbances, such as spasm or achalasia. Reflux and motility disorders may coexist. Esophageal manometry may usefully identify an adynamic esophagus prior to anti-reflux surgery. Although it remains controversial, most surgeons avoid a total fundoplication in the presence of a totally adynamic esophagus. However, not all surgeons utilize esophageal manometry. Major complications are rare, and minor complications are more of a nuisance for the patient, and settle rapidly within a day or so.
Major Complications
Complications associated with esophageal manometry are rare and usually minor in nature, such as nasal bleeding, technical problems with equipment, failure to cannulate, vomiting, and discomfort from a sore throat. Dislodgement or malpositioning may require reinsertion or repeating the procedure. Pain is rarely sequelae. Essentially, there are no major complications with this procedure. Since the patient is alert, the airway is usually sufficiently protected to prevent aspiration pneumonitis. Perforation is an exceedingly rare, but significant complication.
Consent and Risk Reduction
Main Points to Explain
Discomfort/sore throat
Bleeding
Vomiting
Injury to mouth and teeth
Failure to diagnose reflux
Perforation
Pharyngeal Pouch Surgery (Cricopharyngeal Myotomy)
Description
General anesthesia is usually used. Two approaches can be used:
A. Open Approach : Usually, general anesthesia is used; however, in high-risk patients the procedure can be done under local anesthesia. The aim is to divide the constrictive cricopharyngeus muscle. The myotomy is usually carried out posteriorly and is taken from the esophagus below to the pharynx above to be sure that all of the cricopharyngeus muscle is divided. This is sufficient for a small pouch of less than 2 cm in diameter. In medium-sized pouches (2–5 cm) the pouch can be removed or hitched cephalad to the pretracheal fascia. For larger pouches, after performing the myotomy, removal is undertaken using a transverse anastomotic stapling device or sutures. The approach is usually anterior to the carotid sheath and posterior to the strap muscles with the exception of the superior belly of the omohyoid muscle, which is divided. Typically the pouch is dissected free and divided using a TA stapling device.
B. Endoscopic Approach : The procedure is similar to a rigid endoscopy with a modified esophagoscope known as a “Weerda diverticuloscope” being used. One limb of the esophagoscope goes into the pouch and the other into the esophagus so that the common wall between the two is on view. Using an endoscopic camera, an endo-GIA stapler is then placed to divide the common wall, thus carrying out a cricopharyngeal myotomy at the same time as a “pouch to esophagus” anastomosis.
Anatomical Points
Variations occur in the tightness of the cricopharyngeal muscle and the size and orientation of the pouch. Most pharyngeal pouches are left sided. Adhesions may be appreciable, especially in those which are long-standing.
Table 3.3
Pharyngeal pouch surgery (open and endoscopic): estimated frequency of complications, risks, and consequences
Complications, risks, and consequences | Estimated frequency |
|---|---|
Most significant/serious complications | |
Infectiona | 1–5 % |
Subcutaneous | 1–5 % |
Cervical | 0.1–1 % |
Mediastinitis | 0.1–1 % |
Systemic | <0.1 % |
Bleeding/hematoma formationa | 1–5 % |
Esophageal/pharyngeal perforation/leakagea | 1–5 % |
Cervical plexus injury | 1–5 % |
Rare significant/serious problems | |
Injury to mouth, teeth, pharynx, or larynxa | 0.1–1 % |
Pleural/lung infection | 0.1–1 % |
Recurrent laryngeal nerve palsy | 0.1–1 % |
Facial pain | 0.1–1 % |
Recurrent pouch formation/cricopharyngeal spasm | 0.1–1 % |
Cervical fistula | <0.1 % |
Aspiration pneumonitis | 0.1–1 % |
Lymphatic leak/thoracic duct leakage/lymphocele | 0.1–1 % |
Pleural effusion | <0.1 % |
Multisystem organ failurea | <0.1 % |
Deatha | <0.1 % |
Less serious complications | |
Pain/tenderness | |
Acute (<4 weeks) | 50–80 % |
Chronic (>12 weeks) | 1–5 % |
Nasogastric tubea | 0.1–1 % |
Wound scarring (poor cosmesis) | 1–5 % |
Wound drain tube(s)a | 1–5 % |
Perspective
See Table 3.3. In recent years the endoscopic approach has been increasingly used since patients can usually be discharged on the same or the next day after the procedure. The endoscopic approach is not suitable for pouches less than 2 cm in diameter, but it is an ideal approach for patients who are having recurrent pouch surgery. Although both of the procedures are relatively minor procedures, the patients having them are often elderly and/or infirm, so that due to comorbidities, risks and complications from the procedure are higher than would otherwise be the case. However, significant risks may also exist from reflux and/or aspiration of food material from the pouch if surgery is avoided.
Major Complications
Most major complications are related to the comorbidities of the elderly patient rather than the specific procedure per se. Anastomotic leakage is a potentially serious but rare complication leading to infection, which may rarely cause multisystem organ failure and death, in the usually elderly patients having this procedure. Although rare events, recurrent laryngeal nerve injury may cause a hoarse voice; thoracic duct injury may cause a lymphatic sinus or lymphocele, which often settles spontaneously; significant chronic pain or numbness may occur; pouch reformation and aspiration pneumonitis or spontaneous lung infections may occur.
Consent and Risk Reduction
Main Points to Explain
Discomfort/sore throat
Bleeding
Dysphagia
Perforation/leakage
Infection
Injury to mouth and teeth
Failure to correct defect
Recurrence
Open Esophageal (Heller’s) Myotomy (Abdominal Approach)
Description
General anesthesia is used. The aim is to divide the circular muscle of the lower esophageal sphincter. This is done by first removing the fat pad at the gastroesophageal junction on the anterior surface of the junction. A combination of sharp and then blunt dissection is used to disrupt the longitudinal muscle fibers and then the circular muscle fibers, usually anteriorly on the esophagus. This is done by developing a plane between the muscle and the mucosa and then dividing the muscle longitudinally with diathermy or scissors. The myotomy is usually taken proximally, until the thickened region of the lower esophageal sphincter muscle starts to thin out (superior, lower 1/3 of esophagus), and distally, until the stomach is reached, where the plane between the muscle and the mucosa is more difficult to establish and where more bleeding is usually associated with the muscle division. The approach utilized may be open or laparoscopic.
Anatomical Points
The trunk of the anterior vagus nerve usually sweeps across this operative field but is variable in its oblique course from the left to the right side of the lower esophagus. It is usually identified, isolated, and tractioned safely out of the way for the myotomy to be performed.
Table 3.4
Open esophageal long myotomy (Heller’s myotomy): estimated frequency of complications, risks, and consequences
Complications, risks, and consequences | Estimated frequency |
|---|---|
Most significant/serious complications | |
Infectiona | 1–5 % |
Subcutaneous | 1–5 % |
Intra-abdominal | 0.1–1 % |
Mediastinitis | 0.1–1 % |
Systemic | 0.1–1 % |
Bleeding/hematoma formationa | 1–5 % |
Rare significant/serious problems | |
Recurrent achalasia/esophageal spasm | 0.1–1 % |
Esophageal/gastric perforation | 0.1–1 % |
Diaphragmatic injury/hernia | 0.1–1 % |
Mucosal hernia formation (large; inadequate distal myotomy) | 0.1–1 % |
Bowel injury (stomach, duodenum, small bowel, colon) | 0.1–1 % |
Pleural/lung infection/effusion | 0.1–1 % |
Pneumothorax | 0.1–1 % |
Subphrenic abscess | 0.1–1 % |
Gastroesophageal reflux | 0.1–1 % |
Aspiration pneumonitis | 0.1–1 % |
Lymphocele/seroma formation | 0.1–1 % |
Splenectomy | <0.1 % |
Small bowel obstruction (early or late)a [Anastomotic stenosis/adhesion formation] | <0.1 % |
Multisystem organ failurea | <0.1 % |
Deatha | <0.1 % |
Less serious complications | |
Pain/tenderness | |
Acute (<4 weeks) | 50–80 % |
Chronic (>12 weeks) | 1–5 % |
Surgical emphysema | 0.1–1 % |
Incisional hernia formation delayed heavy lifting/straining | 0.1–1 % |
Wound scarring (poor cosmesis) | 1–5 % |
Nasogastric tubea | 1–5 % |
Wound drain tube(s)a | 1–5 % |
Perspective
See Table 3.4. This procedure is almost always undertaken via the laparoscope today because of the superior view obtained and the reduced morbidity compared to open surgery. If the patient has previously had a bag dilatation of the lower esophageal sphincter or botulinum injection, then occasionally the plane between the mucosa and the muscle is obliterated making perforation of the mucosa more likely. Most surgeons undertake some form of fundoplication in association with the myotomy (see section on fundoplication), such as an anterior fundoplication as a Dor patch.
Major Complications
Perforation of the mucosa is the main complication and this is nearly always visible at surgery and should be repaired with a 5-0-monofilament suture. Infection from an unrecognized perforation or failed repair may occur. Patients may have a dilated esophagus and so aspiration during anesthesia, leading to aspiration pneumonitis, is also a possible major complication. Not extending the myotomy far enough is a technical problem that may lead to failure to alleviate symptoms using surgery. Repeat surgery may then be required. Pneumothorax is rare and small if it occurs, usually spontaneously resorbing. Injury to other organs and splenectomy are rare events. Thoracic approaches are associated with the need for a chest drain tube, and a relatively higher risk of chest wall and lung complications (see thoracotomy), but less abdominal complications. Multisystem organ failure and death are very rare and almost always associated with infection and/or cardiorespiratory events.
Consent and Risk Reduction
Main Points to Explain
Discomfort
Bleeding
Dysphagia
Perforation/leakage
Infection
Pneumothorax
Failure to correct defect
Recurrence
Laparoscopic Esophageal Myotomy (Abdominal Approach)
Description
General anesthesia is used. Laparoscopic entry, insufflation of gas, and placement of ports is performed. The aim is to divide the circular muscle of the lower esophageal sphincter. This is done by first removing the fat pad at the gastroesophageal junction on the anterior surface of the junction. A combination of sharp and then blunt dissection is used to disrupt the longitudinal muscle fibers and then the circular muscle fibers, usually anteriorly on the esophagus. This is done by developing a plane between the muscle and the mucosa and then dividing the muscle longitudinally with diathermy or scissors. The myotomy is usually taken proximally, until the thickened region of the lower esophageal sphincter muscle starts to thin out (superior, lower 1/3 of esophagus), and distally, until the stomach is reached, where the plane between the muscle and the mucosa is more difficult to establish and where more bleeding is usually associated with the muscle division.
Anatomical Points
The trunk of the anterior vagus nerve usually sweeps across this operative field but is variable in its oblique course from the left to the right side of the lower esophagus. It is usually identified, isolated, and tractioned safely out of the way for the myotomy to be performed.
Table 3.5
Laparoscopic esophageal long myotomy: estimated frequency of complications, risks, and consequences
Complications, risks, and consequences | Estimated frequency |
|---|---|
Most significant/serious complications | |
Infectiona overall | 1–5 % |
Subcutaneous | 1–5 % |
Intra-abdominal/pelvic | 0.1–1 % |
Systemic | 0.1–1 % |
Port site | 0.1–1 % |
Bleeding/hematoma formationa | |
Wound | 1–5 % |
Intra-abdominal | 0.1–1 % |
Conversion to open operation | 1–5 % |
Rare significant/serious problems | |
Gas embolus | 0.1–1 % |
Deep venous thrombosis | 0.1–1 % |
Mucosal hernia formation (large; inadequate distal myotomy) | 0.1–1 % |
Pleural/lung infection/effusion | 0.1–1 % |
Pneumothorax | 0.1–1 % |
Subphrenic abscess | 0.1–1 % |
Recurrent achalasia/esophageal spasm | 0.1–1 % |
Gastroesophageal reflux | 0.1–1 % |
Aspiration pneumonitis | 0.1–1 % |
Esophageal/gastric perforation | 0.1–1 % |
Diaphragmatic injury/hernia | 0.1–1 % |
Injury to the bowel or blood vessels (trochar or diathermy) | 0.1–1 % |
Duodenal/gastric/small bowel/colonic | |
Liver injury | 0.1–1 % |
Lymphocele/seroma formation | 0.1–1 % |
Splenectomy | <0.1 % |
Possibility of colostomy/ileostomy (very rare)a | <0.1 % |
Small bowel obstruction (early or late)a [Anastomotic stenosis/adhesion formation] | <0.1 % |
Multisystem organ failurea | <0.1 % |
Deatha | <0.1 % |
Less serious complications
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