Improving outcomes after esophagectomy: the importance of preventing postoperative pneumonia

Outcomes after esophagectomy may be related to many factors, including the age of the patient, the stage of the tumor, the operative approach, and the incidence of postoperative morbidity. Pulmonary complications are the major source of morbidity and mortality following esophageal resection, and numerous studies have identified various factors associated with these complications. Preoperative factors affecting pulmonary complications include advanced age, poor nutritional status, and poor cardiopulmonary reserve, whereas preoperative chemoradiation therapy is not clearly associated with increased pulmonary complications. Intraoperative factors associated with increased rates of pulmonary complications include increased blood loss, prolonged operative times, advanced or proximal esophageal tumors, and more extensive operations, including the McKeown resection with three-field lymph node dissection. Postoperative factors associated with pulmonary complications include the development of atrial fibrillation, recurrent laryngeal nerve injury, and aspiration or other abnormality of deglutition. Potential maneuvers to limit the severity of pulmonary complications include smoking cessation prior to surgery, aggressive pulmonary toilet, and documentation of intact swallowing mechanisms prior to the resumption of oral intake after surgery.