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{{Infobox surgical procedure
{{Infobox surgical procedure
| anesthesia_type =  
| anesthesia_type = General
| airway =  
| airway = DLT / SLT + Bronchial blocker
| lines_access =  
| lines_access = Large bore PIV
| monitors =  
NGT
Arterial Line
| monitors = Standard monitors
Invasive hemdynamic
+/- Flowtrack
| considerations_preoperative =  
| considerations_preoperative =  
| considerations_intraoperative =  
| considerations_intraoperative = One-lung ventilation
| considerations_postoperative =  
| considerations_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. 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.
An esophagectomy remains a formidable surgery with high morbidity and mortality.<ref name=":0">{{Cite journal|last=Ng|first=Ju-Mei|date=2008-06|title=Perioperative Anesthetic Management for Esophagectomy|url=https://doi.org/10.1016/j.anclin.2008.01.004|journal=Anesthesiology Clinics|volume=26|issue=2|pages=293–304|doi=10.1016/j.anclin.2008.01.004|issn=1932-2275}}</ref> 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.<ref name=":0" /> 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.<ref>{{Cite journal|last=Jaeger|first=J. Michael|last2=Collins|first2=Stephen R.|last3=Blank|first3=Randal S.|date=2012-12|title=Anesthetic Management for Esophageal Resection|url=https://doi.org/10.1016/j.anclin.2012.08.005|journal=Anesthesiology Clinics|volume=30|issue=4|pages=731–747|doi=10.1016/j.anclin.2012.08.005|issn=1932-2275}}</ref>


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.
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 esophagectomy|Ivor Lewis]] (IL)<ref>{{Cite journal|last=Lewis|first=I.|date=1946-07|title=The surgical treatment of carcinoma of the oesophagus; with special reference to a new operation for growths of the middle third|url=https://pubmed.ncbi.nlm.nih.gov/20994128|journal=The British Journal of Surgery|volume=34|pages=18–31|doi=10.1002/bjs.18003413304|issn=0007-1323|pmid=20994128}}</ref>, McKeown, and [[Transhiatal esophagectomy|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 ==
== Preoperative management ==
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|-
|-
|Cardiovascular
|Cardiovascular
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|Oxygen consumption increases 50% in the immediate post-op period. Patients need to be able to increase cardiac output and oxygen delivery after surgery.
|-
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|Respiratory
|Respiratory
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|Evaluate smoking history and underlying pulmonary dysfunction
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|-
|Gastrointestinal
|Gastrointestinal
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|Patients have passive reflux following esophagectomy.
|-
|-
|Hematologic
|Hematologic
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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. --> ===
* <u>Ivor Lewis</u>: Start supine position for abdominal thorascopic approach and change to left lateral decubitus for thoracic anastamosis
* <u>Transhiatal</u>: 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
# Post-operative atrial fibrillation<ref>{{Cite journal|last=Carney|first=Adam|last2=Dickinson|first2=Matt|date=2015-03|title=Anesthesia for esophagectomy|url=https://pubmed.ncbi.nlm.nih.gov/25701933|journal=Anesthesiology Clinics|volume=33|issue=1|pages=143–163|doi=10.1016/j.anclin.2014.11.009|issn=1932-2275|pmid=25701933}}</ref>
# 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). --> ==
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|+
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!Variant 1
!Open
!Variant 2
!Thoracoscopic
!Robotic
![[Ivor Lewis esophagectomy|Ivor Lewis]]
!McKeown
![[Transhiatal esophagectomy|Transhiatal]]
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|Unique considerations
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|Position
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|Surgical time
|Surgical time
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|EBL
|EBL
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|Postoperative disposition
|Postoperative disposition
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Revision as of 13:22, 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

Article quality
Editor rating
In development
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.[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 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
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. Post-operative atrial fibrillation[4]
  5. Morbidity requiring re-operation
  6. 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)
  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)