Difference between revisions of "Transhiatal esophagectomy"
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{{Infobox surgical case reference | {{Infobox surgical case reference | ||
| anesthesia_type = | | anesthesia_type = General | ||
| airway = | | airway = 8-O ETT | ||
| lines_access = | | lines_access = Large bore PIV | ||
| monitors = | Arterial Line | ||
NG-tube | |||
| monitors = Standard | |||
Arterial Line | |||
| considerations_preoperative = | | considerations_preoperative = | ||
| considerations_intraoperative = | | considerations_intraoperative = | ||
| considerations_postoperative = | | considerations_postoperative = Anastamotic leak | ||
}} | }} | ||
An esophagectomy remains a formidable surgery with high morbidity and mortality<sup>[1]</sup>. 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>{{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>. 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://pubmed.ncbi.nlm.nih.gov/23089506|journal=Anesthesiology Clinics|volume=30|issue=4|pages=731–747|doi=10.1016/j.anclin.2012.08.005|issn=1932-2275|pmid=23089506}}</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<ref name=":1">{{Citation|last=Nottingham|first=James M.|title=Transhiatal Esophagectomy|date=2021|url=http://www.ncbi.nlm.nih.gov/books/NBK559196/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=32644622|access-date=2021-06-17|last2=McKeown|first2=David G.}}</ref>. 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.<ref name=":1" /> | |||
== Preoperative management == | == Preoperative management == | ||
| Line 46: | Line 51: | ||
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | === Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | ||
=== Operating room setup | === Operating room setup === | ||
* 8-O ETT for periemergence bronchoscopy | |||
* Arterial line | |||
* Large bore peripheral IV | |||
* NG tube to decompress stomach | |||
=== Patient preparation and premedication === | |||
* EKG leads on back of shoulders to facilitate neck prep | |||
=== Regional and neuraxial techniques | === Regional and neuraxial techniques === | ||
* Epidural for post-operative pain control | |||
== Intraoperative management == | == Intraoperative management == | ||
=== Monitoring and access | === Monitoring and access === | ||
* Standard ASA Monitors | |||
* Arterial line | |||
=== 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. --> === | ||
| Line 60: | Line 77: | ||
=== 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. --> === | ||
=== Maintenance and surgical considerations | * Supine with both arms tucked | ||
=== Maintenance and surgical considerations === | |||
===== Abdominal laparoscopy: ===== | |||
===== Gastric conduit creation: ===== | |||
===== Esophageal transection: ===== | |||
===== Gastric pull-through: ===== | |||
* Watch peak and plateau pressures for signs of pneumothorax | |||
* Compression of RA may cause sudden hypotension | |||
===== Anastamosis: ===== | |||
* Avoid excessive vasopressors to uphold integrity of anastamosis site | |||
=== 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. --> === | ||
| Line 71: | Line 105: | ||
=== 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. --> === | ||
* Vocal cord palsy | |||
* Anastamotic leak | |||
* General pulmonary failure/complications | |||
== 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). --> == | ||
| Line 76: | Line 114: | ||
{| class="wikitable" | {| class="wikitable" | ||
|+ | |+ | ||
* Very few series have been published comparing robotic and laparoscopic approach. | |||
! | ! | ||
!Laparoscopic | !Laparoscopic | ||
| Line 85: | Line 124: | ||
|- | |- | ||
|Position | |Position | ||
| | |Supine | ||
| | |Supine; arms tucked | ||
|- | |- | ||
|Surgical time | |Surgical time | ||
| | |279min<ref name=":0">{{Cite journal|last=Seto|first=Yasuyuki|last2=Mori|first2=Kazuhiko|last3=Aikou|first3=Susumu|date=2017-09|title=Robotic surgery for esophageal cancer: Merits and demerits|url=https://pubmed.ncbi.nlm.nih.gov/29863149|journal=Annals of Gastroenterological Surgery|volume=1|issue=3|pages=193–198|doi=10.1002/ags3.12028|issn=2475-0328|pmc=5881348|pmid=29863149}}</ref> | ||
| | |267-311min | ||
|- | |- | ||
|EBL | |EBL | ||
| | |88mL<ref name=":0" /> | ||
| | |54-100mL | ||
|- | |- | ||
|Postoperative disposition | |Postoperative disposition | ||
| Line 102: | Line 141: | ||
|Pain management | |Pain management | ||
| | | | ||
| | |Epidural | ||
|- | |- | ||
|Potential complications | |Potential complications | ||
| | | | ||
| | |Pulmonary | ||
Anastamotic leak (9-33%) | |||
Vocal cord palsy (5-30%) | |||
|- | |||
|Length of Stay | |||
|9.2 days<ref name=":0" /> | |||
|9-10 days | |||
|} | |} | ||
Revision as of 15:59, 17 June 2021
Transhiatal esophagectomy
| Anesthesia type |
General |
|---|---|
| Airway |
8-O ETT |
| Lines and access |
Large bore PIV Arterial Line NG-tube |
| Monitors |
Standard Arterial Line |
| Primary anesthetic considerations | |
| Preoperative | |
| Intraoperative | |
| Postoperative |
Anastamotic leak |
| 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 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. 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[3]. 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.[3]
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Neurologic | |
| Cardiovascular | |
| Respiratory | |
| Gastrointestinal | |
| Hematologic | |
| Renal | |
| Endocrine | |
| Other |
Labs and studies
Operating room setup
- 8-O ETT for periemergence bronchoscopy
- Arterial line
- Large bore peripheral IV
- NG tube to decompress stomach
Patient preparation and premedication
- EKG leads on back of shoulders to facilitate neck prep
Regional and neuraxial techniques
- Epidural for post-operative pain control
Intraoperative management
Monitoring and access
- Standard ASA Monitors
- Arterial line
Induction and airway management
Positioning
- Supine with both arms tucked
Maintenance and surgical considerations
Abdominal laparoscopy:
Gastric conduit creation:
Esophageal transection:
Gastric pull-through:
- Watch peak and plateau pressures for signs of pneumothorax
- Compression of RA may cause sudden hypotension
Anastamosis:
- Avoid excessive vasopressors to uphold integrity of anastamosis site
Emergence
Postoperative management
Disposition
Pain management
Potential complications
- Vocal cord palsy
- Anastamotic leak
- General pulmonary failure/complications
Procedure variants
| Laparoscopic | Robotic | |
|---|---|---|
| Unique considerations | ||
| Position | Supine | Supine; arms tucked |
| Surgical time | 279min[4] | 267-311min |
| EBL | 88mL[4] | 54-100mL |
| Postoperative disposition | ||
| Pain management | Epidural | |
| Potential complications | Pulmonary
Anastamotic leak (9-33%) Vocal cord palsy (5-30%) | |
| Length of Stay | 9.2 days[4] | 9-10 days |
References
- ↑ 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) - ↑ 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. PMID 23089506. Check date values in:
|date=(help) - ↑ 3.0 3.1 Nottingham, James M.; McKeown, David G. (2021), "Transhiatal Esophagectomy", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 32644622, retrieved 2021-06-17
- ↑ 4.0 4.1 4.2 Seto, Yasuyuki; Mori, Kazuhiko; Aikou, Susumu (2017-09). "Robotic surgery for esophageal cancer: Merits and demerits". Annals of Gastroenterological Surgery. 1 (3): 193–198. doi:10.1002/ags3.12028. ISSN 2475-0328. PMC 5881348. PMID 29863149. Check date values in:
|date=(help)
Top contributors: Nirav Kamdar, Elmar Malek and Chris Rishel