Thoracic Surgery Expert Opines on Leak Following Esophagectomy

This case involves an elderly male with stage 2 colon cancer and stage 3 esophageal cancer. The plaintiff underwent a minimally invasive esophagectomy. His CT indicated a suspicious leak, although the surgeon was not convinced it was a threat. Patient is then discharged home. That evening he became short of breath with red sputum. His wife called the ambulance and he was taken to a different hospital. The following day the doctors at the new hospital spoke with the fellow from the cancer center who said they had suspected an air leak but it was likely not any worse than when they discharged him. That evening he was emergently intubated and kept in the MICU. He was also noted to have a pericardial effusion without tamponade. Their plan was to stabilize him and send him back to the cancer center. The next day, it was noted there was ongoing bilious fluid in the ETT but there were no beds at the cancer center. On his third day in the new hospital, a bronchoscopy was done, which was concerning for a broncho-esophageal fistula. The next day, he was transferred back to the cancer center where a bronchoscopy and endoscopy showed necrosis of the stomach and lung necessitating debridement and removal of 2/3 of the right lung. The plaintiff continues to need washouts and has pneumonia, delaying his colon cancer treatment.

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?

Expert Witness Response E-088005

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 have taught courses on the technique of the operation.

I routinely get an esophagram on day 6 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 receive an endoscopy and further imaging (CT) in order 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.

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.