Transhiatal esophagectomy

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

An esophagectomy remains a formidable surgery with high morbidity and mortality^[1]. 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^[2]. 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^[3].

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. 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.

Preoperative management

Patient evaluation

System	Considerations
Neurologic
Cardiovascular
Respiratory
Gastrointestinal
Hematologic
Renal
Endocrine
Other

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

Positioning

• Supine with both arms tucked

Maintenance and surgical considerations

Gastric pull-through:

• Watch peak and plateau pressures for signs of pneumothorax
• Compression of RA may cause sudden hypotension

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	267-311min
EBL	88mL	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	9-10 days