Difference between revisions of "Esophagectomy"
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{{Infobox surgical procedure | {{Infobox surgical procedure | ||
| anesthesia_type = General | | anesthesia_type = General | ||
| airway = DLT / | | airway = If thoracic approach: | ||
* DLT | |||
* ETT w/Bronchial blocker | |||
If transhiatal: | |||
* ETT | |||
| lines_access = Large bore PIV | | lines_access = Large bore PIV | ||
NGT | NGT | ||
Art Line | |||
| monitors = Standard monitors | | monitors = Standard monitors | ||
ABP | |||
± Flowtrac | |||
| considerations_preoperative = | | considerations_preoperative = | ||
| considerations_intraoperative = One-lung ventilation | | considerations_intraoperative = One-lung ventilation (if thoracic approach) | ||
| considerations_postoperative = Aspiration | | considerations_postoperative = Aspiration | ||
Vocal cord paresis | Vocal cord paresis | ||
| Line 16: | Line 20: | ||
}} | }} | ||
An esophagectomy remains a formidable surgery with high morbidity and mortality.<ref name=":0">{{Cite journal|last=Ng|first=Ju-Mei|date=June 1, 2008|title=Perioperative Anesthetic Management for Esophagectomy|url=https://doi.org/10.1016/j.anclin.2008.01.004|journal=Anesthesiology Clinics|volume=26|issue=2|pages=293–304|doi=10.1016/j.anclin.2008.01.004|issn=1932-2275|via=}}</ref> It is performed for esophageal cancer<ref>{{Cite journal|last=Napier|first=Kyle J|date=2014|title=Esophageal cancer: A Review of epidemiology, pathogenesis, staging workup and treatment modalities|url=http://www.wjgnet.com/1948-5204/full/v6/i5/112.htm|journal=World Journal of Gastrointestinal Oncology|language=en|volume=6|issue=5|pages=112|doi=10.4251/wjgo.v6.i5.112|issn=1948-5204|pmc=PMC4021327|pmid=24834141}}</ref> and non-malignant conditions including hiatal hernias, severe GERD refractory to medical management, esophageal strictures and diverticula, and dysmotility disorders such as achalasia. | An '''esophagectomy''' is a surgical procedure to remove part of the esophagus and remains a formidable surgery with high morbidity and mortality.<ref name=":0">{{Cite journal|last=Ng|first=Ju-Mei|date=June 1, 2008|title=Perioperative Anesthetic Management for Esophagectomy|url=https://doi.org/10.1016/j.anclin.2008.01.004|journal=Anesthesiology Clinics|volume=26|issue=2|pages=293–304|doi=10.1016/j.anclin.2008.01.004|issn=1932-2275|via=}}</ref> It is performed for esophageal cancer<ref>{{Cite journal|last=Napier|first=Kyle J|date=2014|title=Esophageal cancer: A Review of epidemiology, pathogenesis, staging workup and treatment modalities|url=http://www.wjgnet.com/1948-5204/full/v6/i5/112.htm|journal=World Journal of Gastrointestinal Oncology|language=en|volume=6|issue=5|pages=112|doi=10.4251/wjgo.v6.i5.112|issn=1948-5204|pmc=PMC4021327|pmid=24834141}}</ref> and non-malignant conditions including hiatal hernias, severe GERD refractory to medical management, esophageal strictures and diverticula, and dysmotility disorders such as achalasia. | ||
Anesthetic management depends greatly on the surgical approach. Notably procedures using a thoracic approach typically require one-lung ventilation, while transhiatal procedures do not (see [[#Procedure variants|procedure variants]] for details). The primary anesthetic goals include prevention of tracheal aspiration, lung protective ventilatory strategies, multimodal pain management which may include epidural analgesia, fluid management to optimize tissue oxygen delivery, and adequate perfusion to areas of anastomosis.<ref>{{Cite journal|last=Jaeger|first=J. Michael|last2=Collins|first2=Stephen R.|last3=Blank|first3=Randal S.|date=December 1, 2012|title=Anesthetic Management for Esophageal Resection|url=https://doi.org/10.1016/j.anclin.2012.08.005|journal=Anesthesiology Clinics|volume=30|issue=4|pages=731–747|doi=10.1016/j.anclin.2012.08.005|issn=1932-2275|via=}}</ref> | |||
==Preoperative management == | |||
===Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. -->=== | |||
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> === | |||
{| class="wikitable" | {| class="wikitable" | ||
|+ | |+ | ||
| Line 38: | Line 35: | ||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
|Oxygen consumption increases 50% in the immediate post-op period. Patients need to be able to increase cardiac output and oxygen delivery after surgery. | |Oxygen consumption increases 50% in the immediate post-op period. Patients need to be able to increase cardiac output and oxygen delivery after surgery. | ||
|- | |- | ||
| | |Pulmonary | ||
|Evaluate smoking history and underlying pulmonary dysfunction | |Evaluate smoking history and underlying pulmonary dysfunction | ||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
|Patients have passive reflux following esophagectomy. | | Patients have passive reflux following esophagectomy. | ||
|- | |- | ||
|Hematologic | |Hematologic | ||
| Line 50: | Line 47: | ||
|- | |- | ||
|Renal | |Renal | ||
|Underlying renal insufficiency | |Underlying renal insufficiency may be exacerbated | ||
|- | |- | ||
|Other | |Other | ||
| Line 56: | Line 53: | ||
|} | |} | ||
=== 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. --> === | ===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. -->=== | ||
* Double lumen tube with clamp prepared vs. ETT w/ bronchial blocker vs. ETT (depends on procedure variant) | |||
* Fiberoptic scope to evaluate ETT positioning | |||
* Large gauge NGT +/- bridal as patients remain NPO for >5 days postop | |||
* Arterial line setup | |||
* Significant amounts of crystalloid/colloid ready | |||
* Glucagon 1mg IV (institution and surgeon preference) | |||
=== | ===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. -->=== | |||
Thoracic epidural can be used for intraoperative analgesia, but more importantly can be used for postop pain management with PCEA. | |||
Remember to tape the thoracic tube opposite the side of the thoracotomy incision--thus it should be usually taped to the left. | |||
== | ==Intraoperative management== | ||
===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->=== | |||
*Invasive hemodynamic monitoring | |||
*Large bore IV access | |||
===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->=== | |||
*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 (R lung down) | |||
===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->=== | |||
*Ivor-Lewis | |||
**Start supine position for abdominal thorascopic approach | |||
**Reposition to left lateral decubitus for thoracic anastamosis | |||
*Transhiatal | |||
**Supine throughout | |||
=== | ===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. -->=== | ||
* | * Consider ketamine bolus (0.5 mg/kg) and gtt (0.2-0.5 mg/kg/hr) for pain management intraop | ||
* | *Surgeons may request glucagon for lower esophageal sphincter relaxation | ||
=== | ====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<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->=== | ||
* ICU | ==Postoperative management == | ||
===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->=== | |||
*ICU | |||
* Step-down unit for Enhanced-Recovery cases | * Step-down unit for Enhanced-Recovery cases | ||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->=== | ||
* Epidural | *Epidural utilized for patient controlled epidural analgesia (PCEA) | ||
=== 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 | # Anastomotic leak | ||
# Vocal cord paresis | #Vocal cord paresis | ||
# Recurrent laryngeal nerve injury | #Recurrent laryngeal nerve injury | ||
# Post-operative atrial fibrillation<ref>{{Cite journal|last=Carney|first=Adam|last2=Dickinson|first2=Matt|date=2015-03|title=Anesthesia for esophagectomy|url=https://pubmed.ncbi.nlm.nih.gov/25701933|journal=Anesthesiology Clinics|volume=33|issue=1|pages=143–163|doi=10.1016/j.anclin.2014.11.009|issn=1932-2275|pmid=25701933}}</ref> | #Post-operative atrial fibrillation<ref>{{Cite journal|last=Carney|first=Adam|last2=Dickinson|first2=Matt|date=2015-03|title=Anesthesia for esophagectomy|url=https://pubmed.ncbi.nlm.nih.gov/25701933|journal=Anesthesiology Clinics|volume=33|issue=1|pages=143–163|doi=10.1016/j.anclin.2014.11.009|issn=1932-2275|pmid=25701933}}</ref> | ||
# Morbidity requiring re-operation | #Morbidity requiring re-operation | ||
# Mortality | #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). -->== | |||
Multiple variations of surgical approach are described in the literature. As opposed to traditional open surgery, surgeons have more recently favored minimally invasive thoracoscopic and laparoscopic approaches including robotic-assisted techniques. Minimally invasive approaches allow for optimal visualization within the thoracic cavity to reduce chances of injury during dissection, have reduced pulmonary complications, and shortened the time to recovery.<ref>{{Cite journal|last=Mariette|first=Christophe|last2=Markar|first2=Sheraz R.|last3=Dabakuyo-Yonli|first3=Tienhan S.|last4=Meunier|first4=Bernard|last5=Pezet|first5=Denis|last6=Collet|first6=Denis|last7=D'Journo|first7=Xavier B.|last8=Brigand|first8=Cécile|last9=Perniceni|first9=Thierry|last10=Carrère|first10=Nicolas|last11=Mabrut|first11=Jean-Yves|date=2019-01-10|title=Hybrid Minimally Invasive Esophagectomy for Esophageal Cancer|url=https://pubmed.ncbi.nlm.nih.gov/30625052|journal=The New England Journal of Medicine|volume=380|issue=2|pages=152–162|doi=10.1056/NEJMoa1805101|issn=1533-4406|pmid=30625052}}</ref> Despite the variations, from the anesthesiologist's point of view there are two basic types of esophagectomy: | |||
#Transhiatal | |||
##Chiefly used for tumors in the lower esophagus and adenocarcinoma of the GE junction. | |||
##Does not require one-lung ventilation. Resection is done entirely through the abdomen. | |||
# Combined abdominal/thoracic resection | |||
## Used for complete esophagectomy and tumors high enough in the esophagus that a thoracic approach is necessary. | |||
## Require one-lung ventilation for the thoracic portion of the case (see also [[Video-assisted thoracoscopic surgery|video-assisted thoracic surgery, or VATS]]). | |||
## Two major procedure techniques | |||
###[[Ivor Lewis esophagectomy|Ivor-Lewis esophagectomy]]<ref>{{Cite journal|last=Lewis|first=I.|date=1946-07|title=The surgical treatment of carcinoma of the oesophagus; with special reference to a new operation for growths of the middle third|url=https://pubmed.ncbi.nlm.nih.gov/20994128|journal=The British Journal of Surgery|volume=34|pages=18–31|doi=10.1002/bjs.18003413304|issn=0007-1323|pmid=20994128}}</ref> involves a traditional open laparotomy and open thoracotomy. | |||
###[[McKeown esophagectomy]], adds a third incision in the neck for cervical anastomosis in total esophagectomy. Recent reviews have demonstrated a higher incidence of complications with the McKeown approach.<ref>{{Cite journal|last=van Workum|first=Frans|last2=Slaman|first2=Annelijn E.|last3=van Berge Henegouwen|first3=Mark I.|last4=Gisbertz|first4=Suzanne S.|last5=Kouwenhoven|first5=Ewout A.|last6=van Det|first6=Marc J.|last7=van den Wildenberg|first7=Frits J. H.|last8=Polat|first8=Fatih|last9=Luyer|first9=Misha D. P.|last10=Nieuwenhuijzen|first10=Grard A. P.|last11=Rosman|first11=Camiel|date=January 1, 2020|title=Propensity Score–Matched Analysis Comparing Minimally Invasive Ivor Lewis Versus Minimally Invasive Mckeown Esophagectomy|url=https://journals.lww.com/10.1097/SLA.0000000000002982|journal=Annals of Surgery|language=en|volume=271|issue=1|pages=128–133|doi=10.1097/SLA.0000000000002982|issn=0003-4932|via=}}</ref><ref>{{Cite journal|last=van Workum|first=Frans|last2=Berkelmans|first2=Gijs H.|last3=Klarenbeek|first3=Bastiaan R.|last4=Nieuwenhuijzen|first4=Grard A. P.|last5=Luyer|first5=Misha D. P.|last6=Rosman|first6=Camiel|date=July 1, 2017|title=McKeown or Ivor Lewis totally minimally invasive esophagectomy for cancer of the esophagus and gastroesophageal junction: systematic review and meta-analysis|url=http://jtd.amegroups.com/article/view/13601/11835|journal=Journal of Thoracic Disease|volume=9|issue=S8|pages=S826–S833|doi=10.21037/jtd.2017.03.173|pmc=PMC5538973|pmid=28815080|via=}}</ref> | |||
{| class="wikitable wikitable-horizontal-scroll" | {| class="wikitable wikitable-horizontal-scroll" | ||
|+ | |+ | ||
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|} | |} | ||
== References == | ==References== | ||
[[Category:Surgical procedures]] | [[Category:Surgical procedures]] | ||
<references /> | |||
Latest revision as of 07:06, 4 October 2024
Esophagectomy
| Anesthesia type |
General |
|---|---|
| Airway |
If thoracic approach:
If transhiatal:
|
| Lines and access |
Large bore PIV NGT Art Line |
| Monitors |
Standard monitors ABP ± Flowtrac |
| Primary anesthetic considerations | |
| Preoperative | |
| Intraoperative |
One-lung ventilation (if thoracic approach) |
| Postoperative |
Aspiration Vocal cord paresis Recurrent laryngeal nerve injury Operative mortality |
| Article quality | |
| Editor rating | |
| User likes | 0 |
An esophagectomy is a surgical procedure to remove part of the esophagus and remains a formidable surgery with high morbidity and mortality.[1] It is performed for esophageal cancer[2] and non-malignant conditions including hiatal hernias, severe GERD refractory to medical management, esophageal strictures and diverticula, and dysmotility disorders such as achalasia.
Anesthetic management depends greatly on the surgical approach. Notably procedures using a thoracic approach typically require one-lung ventilation, while transhiatal procedures do not (see procedure variants for details). The primary anesthetic goals include prevention of tracheal aspiration, lung protective ventilatory strategies, multimodal pain management which may include epidural analgesia, fluid management to optimize tissue oxygen delivery, and adequate perfusion to areas of anastomosis.[3]
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Neurologic | |
| Cardiovascular | Oxygen consumption increases 50% in the immediate post-op period. Patients need to be able to increase cardiac output and oxygen delivery after surgery. |
| Pulmonary | Evaluate smoking history and underlying pulmonary dysfunction |
| Gastrointestinal | Patients have passive reflux following esophagectomy. |
| Hematologic | Hypercoagulability due to malignancy |
| Renal | Underlying renal insufficiency may be exacerbated |
| Other |
Labs and studies
Operating room setup
- Double lumen tube with clamp prepared vs. ETT w/ bronchial blocker vs. ETT (depends on procedure variant)
- Fiberoptic scope to evaluate ETT positioning
- Large gauge NGT +/- bridal as patients remain NPO for >5 days postop
- Arterial line setup
- Significant amounts of crystalloid/colloid ready
- Glucagon 1mg IV (institution and surgeon preference)
Patient preparation and premedication
Regional and neuraxial techniques
Thoracic epidural can be used for intraoperative analgesia, but more importantly can be used for postop pain management with PCEA.
Remember to tape the thoracic tube opposite the side of the thoracotomy incision--thus it should be usually taped to the left.
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 (R lung down)
Positioning
- Ivor-Lewis
- Start supine position for abdominal thorascopic approach
- Reposition to left lateral decubitus for thoracic anastamosis
- Transhiatal
- Supine throughout
Maintenance and surgical considerations
- Consider ketamine bolus (0.5 mg/kg) and gtt (0.2-0.5 mg/kg/hr) for pain management intraop
- Surgeons may request glucagon for lower esophageal sphincter relaxation
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
- ICU
- Step-down unit for Enhanced-Recovery cases
Pain management
- Epidural utilized for patient controlled epidural analgesia (PCEA)
Potential complications
- Anastomotic leak
- Vocal cord paresis
- Recurrent laryngeal nerve injury
- Post-operative atrial fibrillation[4]
- Morbidity requiring re-operation
- Mortality
Procedure variants
Multiple variations of surgical approach are described in the literature. As opposed to traditional open surgery, surgeons have more recently favored minimally invasive thoracoscopic and laparoscopic approaches including robotic-assisted techniques. Minimally invasive approaches allow for optimal visualization within the thoracic cavity to reduce chances of injury during dissection, have reduced pulmonary complications, and shortened the time to recovery.[5] Despite the variations, from the anesthesiologist's point of view there are two basic types of esophagectomy:
- Transhiatal
- Chiefly used for tumors in the lower esophagus and adenocarcinoma of the GE junction.
- Does not require one-lung ventilation. Resection is done entirely through the abdomen.
- Combined abdominal/thoracic resection
- Used for complete esophagectomy and tumors high enough in the esophagus that a thoracic approach is necessary.
- Require one-lung ventilation for the thoracic portion of the case (see also video-assisted thoracic surgery, or VATS).
- Two major procedure techniques
- Ivor-Lewis esophagectomy[6] involves a traditional open laparotomy and open thoracotomy.
- McKeown esophagectomy, adds a third incision in the neck for cervical anastomosis in total esophagectomy. Recent reviews have demonstrated a higher incidence of complications with the McKeown approach.[7][8]
| Open | Thoracoscopic | Robotic | Ivor Lewis | McKeown | Transhiatal | |
|---|---|---|---|---|---|---|
| Unique considerations | ||||||
| Position | ||||||
| Surgical time | ||||||
| EBL | ||||||
| Postoperative disposition | ||||||
| Pain management | ||||||
| Potential complications |
References
- ↑ Ng, Ju-Mei (June 1, 2008). "Perioperative Anesthetic Management for Esophagectomy". Anesthesiology Clinics. 26 (2): 293–304. doi:10.1016/j.anclin.2008.01.004. ISSN 1932-2275.
- ↑ Napier, Kyle J (2014). "Esophageal cancer: A Review of epidemiology, pathogenesis, staging workup and treatment modalities". World Journal of Gastrointestinal Oncology. 6 (5): 112. doi:10.4251/wjgo.v6.i5.112. ISSN 1948-5204. PMC 4021327. PMID 24834141.CS1 maint: PMC format (link)
- ↑ Jaeger, J. Michael; Collins, Stephen R.; Blank, Randal S. (December 1, 2012). "Anesthetic Management for Esophageal Resection". Anesthesiology Clinics. 30 (4): 731–747. doi:10.1016/j.anclin.2012.08.005. ISSN 1932-2275.
- ↑ Carney, Adam; Dickinson, Matt (2015-03). "Anesthesia for esophagectomy". Anesthesiology Clinics. 33 (1): 143–163. doi:10.1016/j.anclin.2014.11.009. ISSN 1932-2275. PMID 25701933. Check date values in:
|date=(help) - ↑ Mariette, Christophe; Markar, Sheraz R.; Dabakuyo-Yonli, Tienhan S.; Meunier, Bernard; Pezet, Denis; Collet, Denis; D'Journo, Xavier B.; Brigand, Cécile; Perniceni, Thierry; Carrère, Nicolas; Mabrut, Jean-Yves (2019-01-10). "Hybrid Minimally Invasive Esophagectomy for Esophageal Cancer". The New England Journal of Medicine. 380 (2): 152–162. doi:10.1056/NEJMoa1805101. ISSN 1533-4406. PMID 30625052.
- ↑ Lewis, I. (1946-07). "The surgical treatment of carcinoma of the oesophagus; with special reference to a new operation for growths of the middle third". The British Journal of Surgery. 34: 18–31. doi:10.1002/bjs.18003413304. ISSN 0007-1323. PMID 20994128. Check date values in:
|date=(help) - ↑ van Workum, Frans; Slaman, Annelijn E.; van Berge Henegouwen, Mark I.; Gisbertz, Suzanne S.; Kouwenhoven, Ewout A.; van Det, Marc J.; van den Wildenberg, Frits J. H.; Polat, Fatih; Luyer, Misha D. P.; Nieuwenhuijzen, Grard A. P.; Rosman, Camiel (January 1, 2020). "Propensity Score–Matched Analysis Comparing Minimally Invasive Ivor Lewis Versus Minimally Invasive Mckeown Esophagectomy". Annals of Surgery. 271 (1): 128–133. doi:10.1097/SLA.0000000000002982. ISSN 0003-4932.
- ↑ van Workum, Frans; Berkelmans, Gijs H.; Klarenbeek, Bastiaan R.; Nieuwenhuijzen, Grard A. P.; Luyer, Misha D. P.; Rosman, Camiel (July 1, 2017). "McKeown or Ivor Lewis totally minimally invasive esophagectomy for cancer of the esophagus and gastroesophageal junction: systematic review and meta-analysis". Journal of Thoracic Disease. 9 (S8): S826–S833. doi:10.21037/jtd.2017.03.173. PMC 5538973. PMID 28815080.CS1 maint: PMC format (link)