Esophagectomy
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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. 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.
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 |
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| Neurologic | |
| Cardiovascular | |
| Respiratory | |
| Gastrointestinal | |
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Labs and studies
Operating room setup
Patient preparation and premedication
Regional and neuraxial techniques
Intraoperative management
Monitoring and access
Induction and airway management
Positioning
Maintenance and surgical considerations
Emergence
Postoperative management
Disposition
Pain management
Potential complications
Procedure variants
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