Esophagectomy
Anesthesia type

General

Airway

If thoracic approach:

  • DLT
  • ETT w/Bronchial blocker

If transhiatal:

  • ETT
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

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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.

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

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

  1. Anastomotic leak
  2. Vocal cord paresis
  3. Recurrent laryngeal nerve injury
  4. Post-operative atrial fibrillation[4]
  5. Morbidity requiring re-operation
  6. 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:

  1. Transhiatal
    1. Chiefly used for tumors in the lower esophagus and adenocarcinoma of the GE junction.
    2. Does not require one-lung ventilation. Resection is done entirely through the abdomen.
  2. Combined abdominal/thoracic resection
    1. Used for complete esophagectomy and tumors high enough in the esophagus that a thoracic approach is necessary.
    2. Require one-lung ventilation for the thoracic portion of the case (see also video-assisted thoracic surgery, or VATS).
    3. Two major procedure techniques
      1. Ivor-Lewis esophagectomy[6] involves a traditional open laparotomy and open thoracotomy.
      2. The McKeown (or three-hole) 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

  1. ↑ 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.
  2. ↑ 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)
  3. ↑ 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.
  4. ↑ 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)
  5. ↑ 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.
  6. ↑ 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)
  7. ↑ 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.
  8. ↑ 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)

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