Difference between revisions of "Ivor Lewis esophagectomy"

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{{Infobox surgical procedure
{{Infobox surgical procedure
| anesthesia_type = General
| anesthesia_type = General
| airway = DLT
| airway = DLT / bronchial blocker
| lines_access = Large PIV, arterial line, NG tube
| lines_access = Large PIV, arterial line, NG tube
| monitors = Standard, arterial line
| monitors = Standard, arterial line
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}}
}}


Provide a brief summary of this surgical procedure and its indications here.
The Ivor-Lewis transthoracic esophagectomy can be used to resect cancers in the lower third of the esophagus. It is not the optimal approach for cancers located in the middle third because of the limited proximal margin that can be achieved. This procedure combines a laparotomy with a right thoracotomy and an intrathoracic esophagogastric anastomosis. This approach permits direct visualization of the thoracic esophagus and allows the surgeon to perform a full thoracic lymphadenectomy.  


== Preoperative management ==
== Preoperative management ==
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
{| class="wikitable"
|+
!System
!Considerations
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|Neurologic
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|-
|Cardiovascular
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|-
|Respiratory
|
|-
|Gastrointestinal
|
|-
|Hematologic
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|-
|Renal
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|-
|Endocrine
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|-
|Other
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|}
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===


=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
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* Double-lumen tube (left) / bronchial blocker with SLT
* Double-lumen tube (left) / bronchial blocker with SLT


=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===


=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
* Thoracic epidural (T7-8 commonly)


== Intraoperative management ==
== Intraoperative management ==
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* May consider RSI if high-aspiration risk due to esophageal tumor obstructing food passage
* May consider RSI if high-aspiration risk due to esophageal tumor obstructing food passage
* Left sided double lumen tube or single lumen ETT with bronchial blocker
* Left sided double lumen tube or single lumen ETT with bronchial blocker for one lung ventilation
* NGT placed after airway management


=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===


* Start in supine position if EGD is used  
* Start in supine position if EGD is used at the beginning of the case
* Patient will be later positioned to left lateral decubitus
* Patient will be later positioned to left lateral decubitus for the thoracic portion of the resection


=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
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* Lower portion of the stomach is mobilized
* Lower portion of the stomach is mobilized
* Gastric conduit formed
* Gastric conduit formed
* A cervical anastamosis is performed and esophogus and stomach returned to mediastinum
* A cervical anastomosis is performed and esophagus and stomach returned to mediastinum




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=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
# Anastomotic leak
# Vocal cord paresis
# Recurrent laryngeal nerve injury
# Morbidity requiring re-operation
# Mortality


== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
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|Position
|Position
|
|
|Supine then left
|Supine followed by left


lateral decubitus
lateral decubitus

Latest revision as of 05:55, 1 July 2022

Ivor Lewis esophagectomy
Anesthesia type

General

Airway

DLT / bronchial blocker

Lines and access

Large PIV, arterial line, NG tube

Monitors

Standard, arterial line

Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
Article quality
Editor rating
In development
User likes
0

The Ivor-Lewis transthoracic esophagectomy can be used to resect cancers in the lower third of the esophagus. It is not the optimal approach for cancers located in the middle third because of the limited proximal margin that can be achieved. This procedure combines a laparotomy with a right thoracotomy and an intrathoracic esophagogastric anastomosis. This approach permits direct visualization of the thoracic esophagus and allows the surgeon to perform a full thoracic lymphadenectomy.

Preoperative management

Operating room setup

  • Arterial line +/- flowtrack (ideally on left arm)
  • Fluid warmer
  • Double-lumen tube (left) / bronchial blocker with SLT

Regional and neuraxial techniques

  • Thoracic epidural (T7-8 commonly)

Intraoperative management

Monitoring and access

  • Invasive hemodynamic monitoring
  • Large bore IV access

Induction and airway management

  • May consider RSI if high-aspiration risk due to esophageal tumor obstructing food passage
  • Left sided double lumen tube or single lumen ETT with bronchial blocker for one lung ventilation
  • NGT placed after airway management

Positioning

  • Start in supine position if EGD is used at the beginning of the case
  • Patient will be later positioned to left lateral decubitus for the thoracic portion of the resection

Maintenance and surgical considerations

Abdominal Dissection

  • Pt is placed supine and peritoneal cavity is examined for metastatic disease
  • Lower portion of the stomach is mobilized
  • Gastric conduit formed
  • A cervical anastomosis is performed and esophagus and stomach returned to mediastinum


Emergence

Postoperative management

Disposition

  • Post-op ICU

Pain management

  • Epidural

Potential complications

  1. Anastomotic leak
  2. Vocal cord paresis
  3. Recurrent laryngeal nerve injury
  4. Morbidity requiring re-operation
  5. Mortality

Procedure variants

Open Laparoscopic Robotic
Unique considerations
Position Supine followed by left

lateral decubitus

Surgical time
EBL
Postoperative disposition ICU ICU or ERAS ICU or ERAS
Pain management Thoracic Epidural Thoracic Epidural Thoracic Epidural
Potential complications Anastamotic leak (4.3%)

Vocal cord paresis (0.9%)

Mortality (1.68%)[1]

References

  1. ↑ Luketich, James D.; Pennathur, Arjun; Awais, Omar; Levy, Ryan M.; Keeley, Samuel; Shende, Manisha; Christie, Neil A.; Weksler, Benny; Landreneau, Rodney J.; Abbas, Ghulam; Schuchert, Matthew J. (2012-07). "Outcomes after minimally invasive esophagectomy: review of over 1000 patients". Annals of Surgery. 256 (1): 95–103. doi:10.1097/SLA.0b013e3182590603. ISSN 1528-1140. PMC 4103614. PMID 22668811. Check date values in: |date= (help)

Top contributors: Nirav Kamdar and Olivia Sutton

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