Esophagectomy
| Anesthesia type |
General |
|---|---|
| Airway |
DLT / SLT + Bronchial blocker |
| Lines and access |
Large bore PIV NGT Arterial Line |
| Monitors |
Standard monitors Invasive hemdynamic +/- Flowtrac |
| Primary anesthetic considerations | |
| Preoperative | |
| Intraoperative |
One-lung ventilation |
| Postoperative |
Aspiration Vocal cord paresis Recurrent laryngeal nerve injury Operative mortality |
| Article quality | |
| Editor rating | |
| User likes | 0 |
An esophagectomy 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 may contribute to the improvement of perioperative outcomes. 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 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. 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, and have reduced the pulmonary complications and hastened the recovery period.[4]
Multiple variations of surgical approach are described in the literature. 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. This approach does not require one-lung ventilation, as it is done entirely through the abdomen.
- Combined abdominal/thoracic resection, used for complete esophagectomy and tumors high enough in the esophagus that they cannot be reached from below, and a thoracic approach must be used for dissection and anastomosis. This approach requires one-lung ventilation for the thoracic portion of the case (see also video-assisted thoracic surgery, or VATS).
Ivor-Lewis esophagectomy[5] involves a traditional open laparotomy and open thoracotomy. The McKeown, or three-hole esophagectomy, adds an incision in the neck for cervical anastomosis in total esophagectomy. Both types of procedures may now be done by minimally invasive techniques, with laparoscopy for the abdominal portion and R VATS for the esophageal dissection. Recent reviews have demonstrated a higher incidence of complications with the McKeown approach.[6][7]
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. |
| Respiratory | Evaluate smoking history and underlying pulmonary dysfunction |
| Gastrointestinal | Patients have passive reflux following esophagectomy. |
| Hematologic | Hypercoagulability due to malignancy |
| Renal | Underlying renal insufficiency which may be exacerbated |
| Other |
Labs and studies
Operating room setup
Patient preparation and premedication
Regional and neuraxial techniques
- Thoracic epidural
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
Positioning
- Ivor Lewis: Start supine position for abdominal thorascopic approach and change to left lateral decubitus for thoracic anastamosis
- Transhiatal: Supine
Maintenance and surgical considerations
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 management
Potential complications
- Anastomotic leak
- Vocal cord paresis
- Recurrent laryngeal nerve injury
- Post-operative atrial fibrillation[8]
- Morbidity requiring re-operation
- Mortality
Procedure variants
| 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.
- ↑ 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)
- ↑ 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)