McKeown esophagectomy

McKeown esophagectomy

Anesthesia type	General
Airway	DLT vs SLT w/ bronchial blocker
Lines and access	2 large bore IV, A line
Monitors	Standard ASA monitors, A line
Primary anesthetic considerations
Preoperative	Consider epidural placement for intra/postop analgesia
Intraoperative	RSI induction often necessary, lung isolation
Postoperative	Epidural postop analgesia preferred
Article quality
Editor rating	Comprehensive
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Overview

The Mckeown esophagectomy, also known as the 3-incision or 3-field esophagectomy, is another established method for resection of the esophagus. As with all esophagectomy, indications include treatment of malignant disease in the middle and lower 3rd of the esophagus as well as benign disease such as intractable benign strictures and end stage achalasia. It involves 3 incisions as the name suggests: laparotomy, thoracotomy, and cervical incision. A Mckeown esophagectomy involves thoracic esophageal mobilization and lymph node dissection (either through right open thoracotomy or VATS approach), stomach mobilization and feeding jejunostomy placement (most commonly through laparoscopic methods), and finally left cervical incision for anastomosis.

The Siewert tumor type is assessed to determine the best surgical approach to an esophageal tumor. Siewert type I is defined as tumor located in the lower esophagus within 1cm above and 5cm above the gastroesophageal (GE) junction. Siewert type II involves tumor located within 1cm above and 2cm below the GE junction. Siewert type III tumors are located between 2 and 5cm below the GE junction. Mckeown esophagectomies are best for resecting Siewert type I and II tumors. Although the Ivor Lewis approach is still appropriate for some Siewert type I tumors, tumors located above the carina should only be approached via the Mckeown method due to higher risk of positive margins with the Ivor Lewis approach.

Compared to the more popular Ivor-Lewis approach to esophagectomy, the Mckeown esophagectomy has several advantages, namely lower chance of local recurrence and anastomotic leak is easier to manage and less morbid as the connection is in the neck. The disadvantage is the need for 3 incisions compared to the 2 needed for a traditional Ivor Lewis approach.

Preoperative management

Patient evaluation

System	Considerations
Airway	Malignant lympadenopathy may compress and distort tracheal and bronchial anatomy making placement of DLT more difficult.
Cardiovascular	Elderly patients may have coexisting CAD, preexisting use of antiplatelets or anticoagulants may prevent epidural placement
Pulmonary	atients with esophageal cancer often have a long smoking history and have comorbid COPD. Because this technique uses thoracotomy, evaluate patient for the ability to tolerate one lung ventilation.
Gastrointestinal	Patients with esophageal disease are often at higher risk for aspiration.
Hematologic	Patients with malignant disease may have comorbid anemia

Labs and studies

• Preoperative labwork, cardiac studies, and imaging will vary amongst patient populations. As in all cases, much of the preoperative studies will be based on individual patient H&P
• At a minimum, all patients should have a preoperative hemoglobin and type and screen on file prior to case start
• in patients with a history of cardiac disease or low functional status, consider additional cardiac testing with ECG, echo/stress echo. Any reversible ischemia should prompt further cardiac consultation
• in patients with a history of pulmonary disease, consider further testing with PFTs, ABG and/or flow/volume loops.

Operating room setup

• Standard OR setup
• A-line
• Double lumen tube (left) vs bronchial blocker with SLT
• flexible bronchoscope for DLT placement
• fluid warmer in case transfusion is needed
• forced air warmer

Patient preparation and premedication

• multimodal analgesic technique is recommended.
• thoracic epidural vs ESP block
• consider H2 antagonist and sodium citrate in patients with reflux or partial obstruction

Regional and neuraxial techniques

• because a thoracic approach is utilized, epidural placement for intraop/postop analgesia is recommended in patients without contraindications.

Intraoperative management

Monitoring and access

• standard ASA monitors
• 5 lead EKG
• invasive hemodynamic monitoring with arterial line
• 2 large bore PIV should be
• Central access is often unnecessary

Induction and airway management

• patients with esophageal disease are often at high risk of aspiration, RSI induction with cricoid pressure is usually recommended
• Lung isolation is necessary, placement of a (left) double lumen tube is recommended though other techniques may be used.
• In patients with a difficult airway and high aspiration risk, intubation with a single lumen tube followed by tube exchange vs bronchial blocker can be a viable strategy

Positioning

• patient is positioned in left lateral decubitus for the initial thoracic component
• after completing the thoracic portion of the operation, the patient is repositioned supine with a shoulder roll to allow for the neck to be mildly hyperextended and turned to the right.

Maintenance and surgical considerations

• standard maintenance with volatile or intravenous anesthetics, or balanced technique.
• some surgeons prefer to be involved in the decision to begin vasopressor infusions and may ask for fluid resuscitation prior to initiation of pressors.
• if epidural was placed preoperatively, bolus or continuous infusion of local anesthetic with or without additional epidural opiate can provide intraop analgesia. If epidural opiate loading dose is used to enhance analgesia, administer early during the surgery and at least 1h prior to end of case.

Emergence

• extubation is anticipated in most cases
• aggressive PONV prophylaxis is preferred
• major fluid shifts may occur during surgery which may cause significant airway edema. If extubation is contraindicated, tube exchange to a single lumen tube should be performed prior to transport to ICU.

Postoperative management

Disposition

• PACU then step down unit if extubated
• ICU disposition if postop mechanical ventilation is indicated

Pain management

• epidural postop analgesia with PCEA is preferred
• multimodal analgesia with opioids and/or NSAIDs

Potential complications

• anastomotic leak: less devastating in the 3 hole approach given the cervical location
• chyle leak from thoracic duct injury: initially treated with bowel rest but may need duct ligation or embolization of the cisterna chyli
• recurrent laryngeal nerve injury
• SVT/afib
• thermal injury to membranous bronchus during dissection of subcarinal nodes
• DVT/PE: malignant disease will predispose patients to VTE.
• pulmonary complications (atelectasis, aspiration, pneumonia, pneumothorax)

Procedure variants

Choice of conduit:

There are several choice of conduits to bridge the cervical esophagus to the duodenum to reestablish gastrointestinal continuity.

• Stomach: Most commonly used due to good blood supply and preexisting correct peristaltic direction and orientation. Blood supply to the prepared stomach conduit is from the right epiploic artery and the gastric tip is the most ischemic area especially when under tension. Most centers perform some sort of gastric drainage procedure to prevent delayed gastric emptying (Botox injection, pyloromyotomy or pyloroplasty)
• Jejunum: Given the cervical position of the anastomosis, if jejunum is used, it is typically used as a jejunal free flap can reach from the abdomen to the neck ("supercharged interposition graft"), with microvascular anastomosis performed by plastic surgery. In Ivor Lewis and transhiatal approaches where the anastomosis is in the thorax, Roux-en-Y and pedicled jejunal grafts can be used instead.
• Colon: typically used when stomach is not an option. Either side colon can be used but the left is more commonly used due to smaller caliber, longer length, and fewer vascular variations.