Difference between revisions of "Esophagectomy"

From WikiAnesthesia
(Summary table)
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=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
 
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
 +
 +
* Thoracic epidural
  
 
== Intraoperative management ==
 
== Intraoperative management ==
  
 
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
 
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
 +
 +
* Invasive hemodynamic monitoring
 +
* Large bore IV access
  
 
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
 
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
 +
 +
* 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<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
 
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
 +
 +
* Ivor Lewis: Start supine position for abdominal thorascopic approach and change to left lateral decubitus for thoracic anastamosis
 +
* Transhiatal: Supine
  
 
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
 
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
 +
 +
==== 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<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
 
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
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=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
 
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
 +
 +
* ICU
 +
* Step-down unit for Enhanced-Recovery cases
  
 
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
 
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
 +
 +
* Epidural management
  
 
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
 
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
 +
 +
# Anastomotic leak
 +
# Vocal cord paresis
 +
# Recurrent laryngeal nerve injury
 +
# Morbidity requiring re-operation
 +
# Mortality
  
 
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
 
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

Revision as of 10:59, 2 September 2021

Esophagectomy
Anesthesia type General
Airway DLT / SLT + Bronchial blocker
Lines and access Large bore PIV

NGT

Arterial Line
Monitors Standard monitors

Invasive hemdynamic

+/- Flowtrack
Primary anesthetic considerations
Preoperative
Intraoperative One-lung ventilation
Postoperative Aspiration

Vocal cord paresis Recurrent laryngeal nerve injury

Operative mortality


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.[1] 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.[2]

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. Multiple variations of surgical approaches are described in the literature including Ivor Lewis (IL)[3], McKeown, and transhiatal (TH). While an open approach was used traditionally, surgeons have more recently favored minimally invasive, thoracoscopic, approaches including robotic techniques. Minimally invasive approaches allow for direct visualization within the thoracic cavity to reduce chances of injury during dissection and have reduced the pulmonary complications and hastened the recovery period.

Preoperative management

Patient evaluation

System Considerations
Neurologic
Cardiovascular
Respiratory
Gastrointestinal
Hematologic
Renal
Endocrine
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

  1. Anastomotic leak
  2. Vocal cord paresis
  3. Recurrent laryngeal nerve injury
  4. Morbidity requiring re-operation
  5. Mortality

Procedure variants

Open Thoracoscopic Robotic Ivor Lewis McKeown Transhiatal
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

  1. 1.0 1.1 Ng, Ju-Mei (2008-06). "Perioperative Anesthetic Management for Esophagectomy". Anesthesiology Clinics. 26 (2): 293–304. doi:10.1016/j.anclin.2008.01.004. ISSN 1932-2275. Check date values in: |date= (help)
  2. Jaeger, J. Michael; Collins, Stephen R.; Blank, Randal S. (2012-12). "Anesthetic Management for Esophageal Resection". Anesthesiology Clinics. 30 (4): 731–747. doi:10.1016/j.anclin.2012.08.005. ISSN 1932-2275. Check date values in: |date= (help)
  3. 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)