Difference between revisions of "Transhiatal esophagectomy"

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An esophagectomy remains a formidable surgery with high morbidity and mortality<sup>[1]</sup>. It is performed for esophageal cancer and non-malignant conditions including hiatal hernias, severe GERD refractory to medical management, esophageal strictures and diverticula, and dysmotility disorders such as achalasia<sup>[2]</sup>. Anesthetic management may contribute to the improvement of perioperative outcomes; such factors include prevention of tracheal aspiration, lung protective ventilatory strategies, thoracic epidural analgesia, judicious fluid management to optimize tissue oxygen delivery, and attention to issues that may reduce anastomotic complications<sup>[3]</sup>.
The transhiatal approach is used with a laparotomy below the xiphisternum to mobilize the stomach and create an esophageal conduit from the greater curvature of the stomach. This conduit is brought up to the neck for a gastroesophageal anastamosis at the level of a neck incision.<ref name=":1">{{Citation|last=Nottingham|first=James M.|title=Transhiatal Esophagectomy|date=2021|url=http://www.ncbi.nlm.nih.gov/books/NBK559196/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=32644622|access-date=2021-06-17|last2=McKeown|first2=David G.}}</ref> With advances in laparoscopic and robotic surgical techniques, the transhiatal esophagestomy has been increasing in popularity once again.
 
Esophageal cancer incidence has been increasing and is now the eighth most common malignancy worldwide. Despite overall poor prognosis with this malignancy, surgery plays a significant role to increase long-term survival and possible cure. The transhiatal approach is used with a laparotomy below the xiphisternum to mobilize the stomach and create an esophageal conduit from the greater curvature of the stomach. This conduit is brought up to the neck for a gastroesophageal anastamosis at the level of a neck incision<ref name=":1">{{Citation|last=Nottingham|first=James M.|title=Transhiatal Esophagectomy|date=2021|url=http://www.ncbi.nlm.nih.gov/books/NBK559196/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=32644622|access-date=2021-06-17|last2=McKeown|first2=David G.}}</ref>. While an open approach was used traditionally, surgeons changed to favor the transthoracic approach originally described by Ivor Lewis. With advances in laparoscopic and robotic surgical techniques, the transhiatal esophagestomy has been increasing in popularity once again. Thoracoscopic and robotic approaches have reduced the pulmonary complications and hastened the recovery period. Minimally invasive approaches allow for direct visualization within the thoracic cavity to reduce chances of injury during dissection.<ref name=":1" />   
 
== Preoperative management ==
== Preoperative management ==


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===== Abdominal laparoscopy: =====
===== Abdominal laparoscopy: =====


===== Gastric anastamosis: =====
===== Gastric conduit creation: =====


===== Esophageal transection: =====
===== Esophageal transection: =====


===== Gastric pull-through: =====
===== Gastric pull-through: =====
* Watch peak and plateau pressures for signs of pneumothorax
* Compression of RA may cause sudden hypotension


===== Anastamosis: =====
===== Anastamosis: =====
* Avoid excessive vasopressors to uphold integrity of anastamosis site


=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
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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. --> ===
* Vocal cord palsy
* Anastamotic leak
* General pulmonary failure/complications


== 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). --> ==

Latest revision as of 21:46, 21 February 2022

Transhiatal esophagectomy
Anesthesia type

General

Airway

8-O ETT

Lines and access

Large bore PIV Arterial Line NG-tube

Monitors

Standard Arterial Line

Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative

Anastamotic leak

Article quality
Editor rating
Unrated
User likes
0

The transhiatal approach is used with a laparotomy below the xiphisternum to mobilize the stomach and create an esophageal conduit from the greater curvature of the stomach. This conduit is brought up to the neck for a gastroesophageal anastamosis at the level of a neck incision.[1] With advances in laparoscopic and robotic surgical techniques, the transhiatal esophagestomy has been increasing in popularity once again.

Preoperative management

Patient evaluation

System Considerations
Neurologic
Cardiovascular
Pulmonary
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Labs and studies

Operating room setup

  • 8-O ETT for periemergence bronchoscopy
  • Arterial line
  • Large bore peripheral IV
  • NG tube to decompress stomach

Patient preparation and premedication

  • EKG leads on back of shoulders to facilitate neck prep

Regional and neuraxial techniques

  • Epidural for post-operative pain control

Intraoperative management

Monitoring and access

  • Standard ASA Monitors
  • Arterial line

Induction and airway management

Positioning

  • Supine with both arms tucked

Maintenance and surgical considerations

Abdominal laparoscopy:
Gastric conduit creation:
Esophageal transection:
Gastric pull-through:
  • Watch peak and plateau pressures for signs of pneumothorax
  • Compression of RA may cause sudden hypotension
Anastamosis:
  • Avoid excessive vasopressors to uphold integrity of anastamosis site

Emergence

Postoperative management

Disposition

Pain management

Potential complications

  • Vocal cord palsy
  • Anastamotic leak
  • General pulmonary failure/complications

Procedure variants

  • Very few series have been published comparing robotic and laparoscopic approach.
Laparoscopic Robotic
Unique considerations
Position Supine Supine; arms tucked
Surgical time 279min[2] 267-311min
EBL 88mL[2] 54-100mL
Postoperative disposition
Pain management Epidural
Potential complications Pulmonary

Anastamotic leak (9-33%)

Vocal cord palsy (5-30%)

Length of Stay 9.2 days[2] 9-10 days

References

  1. ↑ Nottingham, James M.; McKeown, David G. (2021), "Transhiatal Esophagectomy", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 32644622, retrieved 2021-06-17
  2. ↑ 2.0 2.1 2.2 Seto, Yasuyuki; Mori, Kazuhiko; Aikou, Susumu (2017-09). "Robotic surgery for esophageal cancer: Merits and demerits". Annals of Gastroenterological Surgery. 1 (3): 193–198. doi:10.1002/ags3.12028. ISSN 2475-0328. PMC 5881348. PMID 29863149. Check date values in: |date= (help)

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