The nightmare of an oesophageal surgery
Anonymous said to @ask-drferox: Why are intra-thoracic esophagus surgeries a nightmare?
I have honestly never seen a patient survive oesophageal surgery, and have gone to great lengths to try to avoid patients needing one.
To begin with, most of the oesophagus is in the thorax, and there’s a reason ‘open chest surgery’ inspires a certain degree of awe and dread. You have to crack open those ribs, and as soon as you enter the chest cavity the patient can no longer breathe on their own.
Breathing in mammals works because of negative pressure. The lungs are kind of elastic, so when the chest wall moves outwards, or the diaphragm moves down, it causes them to expand to fill the larger space. When the chest cavity is open, that can’t happen, because air is sucked into the hole (outside the lungs) instead. The chest wall and diaphragm can move all you like, but the air doesn’t move in the lungs.
So instead, you either need a ventilator, or somebody has to sit there and breathe for the patient the entire time, pushing air into its lungs. And afterwards, if it all goes well, you gotta close up with a chest drain and manage that so that the patient will continue to breathe.
Next, you have to actually reach the oesophagus. This organ runs from the head, down the neck, into the chest, over the heart and then through the diaphragm to the heart. Guess where the three narrowest parts are that obstructions usually get stuck are? The entrance to the thorax, passing through the diaphragm, and directly over the heart. That beating mass of muscle that you don’t really want to mess with.
Now, if we’re going well, we need to cut into that oesophagus. And this is also a problem.
The rest of the gastrointestinal tract has wiggle room. You can cut out a third of the small intestine if you really want to, and large chunks of stomach or colon. You have basically no ‘excess’ in an oesophagus that you can remove without putting it under too much tension. There is a minimum distance that it simply must cover. If it’s under too much tension, the surgical site will simply break apart.
It also, unlike organs in the abdomen, has no serosa (except the little bit that’s inside the abdomen). This is the outer layer of the organ that makes the seal at the surgical site water proof, and without it the oesophagus is very, very prone to leaking.
And leaking into the thoracic cavity is going to be Bad News.
Considering the most common reason for needing to cut into the oesophagus is to remove a foreign object that’s stuck, there’s also a lot of damaged, compromised tissue there which might break down, especially if that object is hard or pointy like a bone.
Alternatives to oesophageal surgery are trying to pull the object back up the way it came, or push it into the stomach and cut out out of the good old reliable stomach, but both of those options have risks of causing further damage on the way up or down too.
I’m just tapping out on these cases, they can go to a specialist (as all the others I’ve been involved with have done, and even then did not go well). Once you’re seriously talking about cracking open that chest, I’m not optimistic.
