Esophagectomy Causes Necrosis in Patient’s Lung

This case involves a 32-year-old female with stage II esophageal cancer who underwent a minimally invasive esophagectomy. 5 days after the operation, she had a CT scan that showed a suspicious area, but the surgeon was convinced that it was simply some air, rather than a leak. The patient was discharged home 2 weeks after her operation. However, the day after she was discharged, she started to cough up blood. Her father called the ambulance and she was taken to a nearby hospital, rather than the cancer center where she had her surgery. The doctors at the new hospital spoke with the fellow from the cancer center who said they had suspected an air leak but believed it was not serious. She could not immediately be transported to the cancer center because the it was miles away and her unstable condition could not yet be supported. She continued to have trouble breathing and her condition declined. A bronchoscopy was performed at the hospital, which raised concerns for a bronchoesophageal fistula. The following day, they were able to transfer her to the cancer center where a bronchoscopy and endoscopy showed necrosis of the left lung, necessitating its removal.

Question(s) For Expert Witness

1. How often do you perform minimally invasive esophagectomies?

2. What labs, tests or milestones, if any, indicate a patient is ready for discharge after an esophagectomy?

3. Are you able to opine on if the delay in diagnosis of the fistula affected the extent of the following surgeries and/or overall prognosis?

4. Have you ever reviewed a similar case? If yes, please explain.

Expert Witness Response E-088005

I would be happy to review this case if your client would like and do have expertise in the area. I have included answers to your questions below. 1. I perform MIE?s routinely (1-2 per month); and have advanced fellowship training specifically in MIE at the University of Pittsburgh, where the operation was invented. I was then on the faculty at UPMC for 2 years, working in a practice where, with my senior partner, we did roughly 100 MIE?s per year. I have also written several chapters on MIE and taught courses on the technique of the operation. 2. I routinely get an esophagram on POD6 or 7 after an esophagectomy as I believe this is the most sensitive test for an anastomotic leak. If this indicates a leak the patient at a minimum should get an endoscopy and further imaging (CT) to determine if they require any operative intervention at that time. I routinely leave a drain adjacent to the anastomosis and in many cases this allows for the avoidance of another operation. 3. The presence of the fistula is a major complication. The need for a lung resection is unusual, but not unheard of in this setting. However, any delay would make it more difficult to control the mediastinal and pleural sepsis and complicate the operation. It also will increase the damage to the remaining lung and may worsen the PNA. 4. I have not been involved in the review of other cases like this one 5. I have not been arrested or sued.