Anesthesiologist's Manual of Surgical Procedures, 4th ed.

General Surgery

Chapter 7.1

Esophageal Surgery

Richard I. Whyte MD

Surgeon

Jeffrey Norton MD

Surgeon

Vivek Kulkarni MD

Anesthesiologist

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Esophagostomy

Surgical Considerations

Description: Esophagostomy is performed to divert oral secretions away from the esophagus to a stoma in certain types of esophageal perforation. To perform an esophagostomy, the esophagus is approached through a left cervical incision. The sternocleidomastoid muscle and carotid sheath are retracted laterally and the thyroid medially, exposing the cervical esophagus (Fig. 7.1-1). The esophagus is mobilized with care being taken not to injure the left recurrent laryngeal nerve which typically lies in the tracheoesophageal groove. The esophagus is brought to the skin surface as a loop or end stoma and sutured to the skin with absorbable sutures.

Variant procedure or approaches: The procedure is usually performed via a left cervical approach; the right side is an alternative.

Usual preop diagnosis: Esophageal perforation; distal esophageal obstruction

Summary of Procedures

Position

Supine, with head rotated to right

Incision

Cervical

Antibiotics

Cefazolin 1 g iv preop

Surgical time

45 min

EBL

2550 mL

Postop care

Stoma pouch to collect saliva
PACU → ward

Mortality

< 0.1%

Morbidity

Skin irritation: 1520%
Saliva leakage: 510%
Wound infection: < 5%
Recurrent laryngeal nerve injury: 12%

Pain score

57

Patient Population Characteristics

Age range

20–60 yr

Male:Female

1:1

Incidence

Not uncommon

Etiology

Surgically created

Associated conditions

Esophageal perforation; pharyngeal cancer

Anesthetic Considerations

See Anesthetic Considerations for Esophageal Surgery following Esophagectomy, p. 482.

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Figure 7.1-1. Surgical anatomy for cervical esophagostomy. (Reproduced with permission from Nora PF, ed: Operative Surgery Principles and Techniques. WB Saunders, Philadelphia: 1990.)

Suggested Reading

  1. Jones WG, Ginsberg RJ: Esophageal perforations: a continuing challenge. Ann Thorac Surg1992; 53:534.

Esophageal Diverticulectomy

Surgical Considerations

Description: Esophageal diverticula are divided into three anatomic types: pharyngoesophageal (Zenker's), midesophageal, and epiphrenic. Structurally, they are either “true” diverticula—meaning they consist of all three layers of the esophageal wall (mucosa, submucosa, and muscularis)—or “false” diverticula consisting of

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only mucosa (or mucosa and submucosa). Pharyngoesophageal diverticula account for 60–65% of all cases. These are false diverticula that originate in Killian's triangle, a weak point in the posterior esophagus, just proximal to the transverse fibers of the cricopharyngeal muscle (Fig. 7.1-2). They are associated with incomplete, or discoordinate, upper esophageal sphincter relaxation and the resultant increased hypopharyngeal pressure produces a narrow-mouthed posterior diverticulum. These diverticula frequently present in the seventh decade and are 2–3 times more common in men. Symptoms depend on the stage of the disease. Early on, patients may complain of vague pharyngeal sensations, dysphagia, cough, and excess salivation. Later, more severe symptoms—such as severe (or frequent) dysphagia, regurgitation of food, halitosis, voice changes, aspiration, and odynophagia (painful swallowing)—may occur.

 

Figure 7.1-2. Formation of Zenker's diverticulum. A. Herniation of the pharyngeal mucosa and submucosa occurs at the point of potential weakness (Killian's triangle [arrow]) between the oblique fibers of the thyropharyngeus muscle and the more horizontal fibers of the cricopharyngeus muscle. B. As the diverticulum enlarges, it drapes over the cricopharyngeus sphincter and descends into the superior mediastinum in the prevertebral space. (Reproduced with permission from Greenfield LJ, Mulholland, MW, Oldham KT, et al, eds: Surgery: Scientific Principles and Practice, 3rd edition. Lippincott Williams & Wilkins, Philadelphia: 2001. After Orringer MB: Diverticula and miscellaneous conditions of the esophagus. In Textbook of Surgery, 13th edition. Sabiston DC Jr, ed. WB Saunders, Philadelphia: 1986.)

Surgery is the only effective therapy for Zenker's diverticulum. Respiratory complications (aspiration) or nutritional deficiencies (weight loss) may be directly attributable to the diverticulum and should not be contraindications to surgery. Multiple different operative approaches are advocated: diverticulectomy alone, cricopharyngeal myotomy, diverticulectomy with myotomy, and myotomy with suspension of the diverticulum. Myotomy alone, which corrects the underlying physiologic abnormality, is up to 78% effective and may be considered for patients with small (< 2 cm) diverticula. Diverticulectomy or suspension should be added if the diverticulum itself is large or dependant. Both procedures are performed via a left cervical incision (Fig. 7.1-3: inset) and are associated with a low rate of recurrence and complications. The upper esophagus is exposed by retracting the sternocleidomastoid muscle and carotid sheath laterally and the thyroid gland medially. The diverticulum is located in the prevertebral space. Care is taken not to injure the recurrent laryngeal nerve. Following excision of the diverticulum, a cricopharyngeal myotomy may be performed, starting on the upper esophagus and extending across the cricopharyngeal muscle near the neck of the diverticulum, and on to the inferior pharyngeal constrictor muscle.

Recent emphasis has been placed on endoscopic treatment of Zenker's diverticulum (Dohlman procedure). In this procedure, a modified laryngoscope and endoscopic stapler are used to divide the common wall between diverticulum and true esophageal lumen.

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Figure 7.1-3. Zenker's diverticulum approached through a left cervical incision (inset). A. The diverticulum is grasped and a cricopharyngeal myotomy is extended onto the upper esophagus. B. The base of the diverticulum is stapled and the diverticulum is resected. (Reproduced with permission from Shields TW, LoCicero J III, Ponn RB: General Thoracic Surgery, 5th edition. Lippincott Williams & Wilkins, Philadelphia: 2000.)

Midesophageal diverticula, by definition, occur in the middle 3rd of the esophagus. These “true” diverticula typically arise in the setting of mediastinal granulomatous disease whereby a fibrotic reaction around inflamed mediastinal lymph nodes results in traction on the muscular wall of the esophagus. Diverticula usually arise within 4–5 cm of the carina and comprise an estimated 10–17% of all esophageal diverticula. Most midesophageal diverticula are asymptomatic and do not require surgical intervention. In cases that require intervention, because of either regurgitation or development of an esophagobronchial fistula, the approach is through a right thoracotomy with excision of the inflammatory mass. Primary closure of the fistula and the interposition of viable tissue should be performed.

Epiphrenic diverticula arise in the distal 10 cm of the esophagus and are thought to be related to an underlying esophageal motility disorder. These false diverticula are most commonly present in the 6th decade. The clinical presentation is variable, with most patients presenting with symptoms related to their underlying dysmotility syndrome: dysphagia, chest pain, or regurgitation. Most patients with epiphrenic diverticula are asymptomatic, and there appears to be no relation between size of the diverticulum and symptoms. Surgery for epiphrenic diverticula typically consists of diverticulectomy with myotomy either through a left thoracotomy (Fig. 7.1-4) or via laparoscopy. With the transthoracic approach, a low, left thoracotomy is used, the esophagus is mobilized and encircled, and the diverticulum is mobilized and excised. A myotomy should be performed opposite the diverticulectomy and should extend proximally above the diverticulum and distally onto the stomach. Because there is, by definition, an underlying motility disorder, the myotomy should be carried onto the stomach and a nonobstructing fundoplication may be added to prevent significant postoperative reflux.

Variant procedure or approaches: Laparoscopic diverticulectomy and myotomy has gained increasing acceptance, and reported outcomes are similar to those obtained with the open procedure. The surgical approach is similar to that used during laparoscopic fundoplication (see p. 571). Dissection of the diverticula may be facilitated by the passage of a bougie or video endoscope. After the diverticulum is amputated using an endoscopic stapler, a myotomy is performed opposite the diverticula and a partial fundoplication is fashioned.

Usual preop diagnosis: Esophageal diverticulum

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Figure 7.1-4. Epiphrenic diverticulum. Through a left thoracotomy, the diverticulum is mobilized and resected. A contralateral myotomy is then created and extended distally to the stomach to eliminate any functional obstruction secondary to the pre-existent dysmotility. (Reproduced with permission from Shields TW, LoCicero J III, Ponn RB: General Thoracic Surgery, 5th edition. Lippincott Williams & Wilkins, Philadelphia: 2000.)

Summary of Procedures

 

Hypopharyngeal

Epiphrenic

Position

Supine

Right lateral decubitus

Incision

Left or right cervical

Left thoracotomy

Special instrumentation

None

Chest retractor

Unique considerations

Care not to injure recurrent laryngeal nerve

10 cm myotomy

Antibiotics

Cefazolin 1 g iv preop

Surgical time

1–2 h

Closing considerations

Inspect for perforation

EBL

50–100 mL

100–200 mL

Postop care

PACU → ward

ICU × 1–2 d

 

Hypopharyngeal

Epiphrenic

Mortality

< 1%

Morbidity

Recurrent nerve paralysis: < 5%
Temporary phonetic problems: < 5%
Esophageal stricture: < 3%
Esophageal fistula: < 2%

Atelectasis: 5–10%
Esophageal perforation: < 2%
< 2%

Pain score

6–7

7–9

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Patient Population Characteristics

Age range

35–90 yr (50% of patients > 70 yr)

Male:Female

2:1

Incidence

Uncommon

Etiology

Uncoordinated cricoesophageal muscle and lower esophageal sphincter; weakness of esophageal wall.

Associated conditions

Cachexia (25–30%); hiatus hernia with or without reflux (25%); chronic pulmonary infection (15–20%); aspiration (30–40%)

Anesthetic Considerations

See Anesthetic Considerations for Esophageal Surgery following Esophagectomy, p. 482.

Suggested Readings

  1. Deschamps C, Trastek V: Esophageal diverticula. In: General Thoracic Surgery,5th edition. Shields TW, LoCicero J III, Ponn RB, eds. Lippincott Williams & Wilkins, Philadelphia: 2000.
  2. Ferreira LE, Simmons DT, Bain TH: Zenker's diverticula: pathophysiology, clinical presentation, and flexible endoscopic management. Dis Esophagus2008;21:1–8.

Management of Esophageal Perforation

Surgical Considerations

Description: Esophageal perforation may be spontaneous, instrumental (iatrogenic), traumatic, or 2° intrinsic esophageal disease. Spontaneous (or emetogenic) perforation most commonly occurs in the lower 3rd of the esophagus. Instrumental perforations may occur at any level, but are most common just above the cardia and in the cervical esophagus. The level of traumatic perforation depends on the location of the penetrating wound. Sx of esophageal perforation at the cricopharyngeal sphincter include neck pain, fever, and crepitations in the substernal and neck areas. Perforation in the mediastinum may result in hydropneumothorax, mediastinitis, fever, and substernal pain. Cervical perforations are managed with antibiotics and drainage in the cervical area. Therapy for intrathoracic perforation generally requires emergent operation. Surgical options include primary repair, drainage and diversion, and esophageal resection. The optimal choice depends on the nature and duration of the perforation as well as the clinical condition of the patient. Spontaneous perforations are often amenable to primary repair—either through the abdomen or the left chest. Patients suffering from iatrogenic perforation incurred during dilation of a malignant, or nondilatable, stricture may require urgent esophagectomy. Patients with delayed recognition of a perforation may be hemodynamically unstable and may only tolerate drainage and diversion (generally through a cervical esophagostomy).

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Variant procedure or approaches: Cervical or right thoracic drainage is indicated when the perforation occurs in the neck or high in the mediastinum.

Usual preop diagnosis: Esophageal perforation

Summary of Procedures

 

Left Thoracotomy

Cervical or Thoracic Drainage

Position

Right lateral decubitus

Supine or right lateral decubitus

Incision

Left thoracotomy

Cervical or right chest

Antibiotics

Zosyn (piperacillin & tazobactom) 3.375 g iv q6h

VTE prophylaxis

Heparin 5,000 units sq

Surgical time

2–4 h

1 h

Closing considerations

Chest drain

Cervical or thoracic drain

EBL

100–200 mL

50–100 mL

Postop care

Chest tube to suction; PACU → ward

Mortality

5–10%

2–5%

Morbidity

Pneumonia: 5–10%
Esophageal leak: 2–5%
Pericarditis: 1–3%


10%

Pain score

8–10

8–10

Patient Population Characteristics

Age range

Variable: 20–80 yr

Male:Female

1:1

Incidence

1 in 8,000 admissions

Etiology

Instrumental (endoscopy, dilatation, intubation); traumatic (penetrating, foreign body, caustic agents); intrinsic disease (carcinoma, peptic ulceration); spontaneous

Associated conditions

Esophageal stricture (75%); cancer (25%)

Anesthetic Considerations

See Anesthetic Considerations for Esophageal Surgery following Esophagectomy, p. 482.

Suggested Readings

  1. Fell SC: Esophageal perforation. In: Esophageal Surgery.Pearson FG, Cooper JD, Deslauriers J, et al, eds. Churchill Livingstone, New York: 2002, 615–36.
  2. Orringer MB: The mediastinum. In: Operative Surgery,3rd edition. Nora PF, ed. WB Saunders, Philadelphia: 1990, 370–3.
  3. Wong AS, Myers JC, Jamieson GG: Esophageal pH profile after laparoscopic total fundoplication compared to anterior fundoplication. J Gastrointest Surg2008; in press.
  4. Wu JT, Mattox KL, Wall MJ: Esophageal perforations: new perspectives and treatment paradigms. J Trauma2007;63:1173–84.

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Esophagomyotomy

Surgical Considerations

Description: Esophagomyotomy is performed for achalasia and other motility disorders to facilitate esophageal emptying into the stomach. Most authors recommend incising the muscular layer of the distal esophagus and continuing down across the gastroesophageal junction for at least 1 cm (Heller's myotomy). The muscle is dissected back from the mucosa so that roughly 180° is exposed (Fig. 7.1-5). The distal esophagus is mobilized either from below the diaphragm or via a left thoracic approach. Care is taken not to injure the vagus nerves.

When approached from the abdomen, the esophagus is exposed by incising the gastroesophageal ligament. The distal esophagus is mobilized and pulled downward to perform the myotomy.

Variant procedure or approaches: The procedure usually is performed through a left thoracotomy, but some surgeons prefer a transabdominal approach. More recently, laparoscopic or thoracoscopic approaches are being employed to perform esophagomyotomy (see p. 574).

 

Figure 7.1-5. Surgical anatomy for esophagomyotomy. (Reproduced with permission from Hardy JD: Hardy's Textbook of Surgery, 2nd edition. JB Lippincott, Philadelphia: 1988.)

Usual preop diagnosis: Achalasia; diffuse esophageal spasm; nutcracker esophagus

Summary of Procedures

 

Thoracic Approach

Abdominal Approach

Endoscopic Approaches

Position

Right lateral decubitus

Supine

Supine

Incision

Left thoracotomy in 6th interspace

Midline upper abdomen

Multiple small abdominal incisions

Special instrumentation

Chest retractor

Denier retractor

Laparoscopic instrumentation

Unique considerations

Care should be taken to avoid extending gastric myotomy too far to prevent esophageal reflux.

Legs spread apart (laparoscopic approach)

Antibiotics

Cefazolin 1–2 g iv preop

VTE prophylaxis

Heparin 5,000 units sq

Surgical time

1–2 h

Closing considerations

[check mark] for perforation. Consider fundoplication to prevent esophageal reflux.

EBL

150–200 mL

100–150 mL

50 mL

Postop care

ICU × 1–2 d

PACU → room

Mortality

< 0.5%

Morbidity

Esophagitis: ≥ 20%
Transient dysphagia/reflux: 5%
Esophageal leak: 1–2%





Pain score

7–9

6–8

3–4

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Patient Population Characteristics

Age range

30–50 yr

Male:Female

1:1

Incidence

0.6/100,000

Etiology

Neuromuscular disorder of unknown etiology often characterized by absence of ganglion cells of Auerbach's plexus.

Associated conditions

Predisposition to development of carcinoma (1–20%); pulmonary complications 2° aspiration (5–10%)

Anesthetic Considerations

See Anesthetic Considerations for Esophageal Surgery following Esophagectomy, p. 482.

Suggested Readings

  1. Ellis FH Jr, Crozier RE, Watkins E Jr: Operation for esophageal achalasia. Results of esophagomyotomy without an antireflex. J Thorac Cardiovasc Surg1984; 88(3):344–51.
  2. Pellegrini C, Wetters LA, Palti M, et al: Thorascopic esophagomyotomy. Ann Surg1992; 216:29.
  3. Stuart RC, Hennessy TP: Primary motility disorders of the esophagus. Br J Surg1989; 76:111.
  4. Zhu ZJ, Chen LQ, Duranceau A: Long-term results of total vs. partial fundoplication after esophagomyotomy for primary esophageal motor disorders. World J Surg2008; 32:401–7.

Esophagogastric Fundoplasty

Surgical Considerations

Description: Esophagogastric fundoplasty represents a variety of operations designed to prevent esophageal reflux by wrapping the fundus of the stomach around a 3–4 cm segment of the lower esophagus. This fundal wrapping acts to reinforce the lower esophageal sphincter. Surgery may be performed transabdominally, transthoracically, or laparoscopically, depending on surgeon's preference. The most common approach is the open or laparoscopic Nissen fundoplication, wherein the anterior and posterior walls of the stomach are sutured together around the lower esophagus with nonabsorbable sutures (Fig. 7.1-6A). This is accomplished by incising the gastrosplenic ligament and ligating three or four short gastric vessels. Care must be taken not to injure the spleen or vagus nerves during the repair.

Variant procedure or approaches: Modifications of the Nissen fundoplication include the Toupet procedure, a posterior partial fundoplication, and the Hill procedure, in which the gastroesophageal junction is sutured to the median arcuate ligament of the diaphragm or to the preaortic fascia (Fig. 7.1-6B). Another modification is the Belsey Mark IV repair, in which there is a 240° semifundoplication between the stomach and esophagus, making it easier for the patient to overcome the resistance of the wrap. There are proponents of each repair, although the Nissen fundoplication remains the standard to which others are compared. The laparoscopic approach is widely used, although the left transthoracic approach provides excellent exposure for either Nissen or Belsey repairs (see p. 574).

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Figure 7.1-6. A. Nissen fundoplication may be performed via either the transabdominal or transthoracic approach; B. Hill repair is performed through the abdomen. (Reproduced with permission from Hardy JD: Hardy's Textbook of Surgery, 2nd edition. JB Lippincott, Philadelphia: 1988.)

Usual preop diagnosis: Sliding hiatus (hiatal) hernia, paraesophageal hiatus hernia, or free reflux

Summary of Procedures

 

Nissen (Toupet) Fundoplication

Laparoscopic Nissen

Hill Procedure

Belsey Mark IV

Position

Supine

Supine, legs apart

Right lateral decubitus

Incision

Midline abdominal or laparoscopic ports

Laparoscopic ports

Midline abdominal

Left posterolateral thoracotomy

Special instrumentation

#40–50 Hurst dilators; NG tube

Laparoscopic instrumentation

NG tube

Chest retractor; NG tube

Unique considerations

Fundoplication should be loose; parietal cell vagotomy performed if peptic ulcer disease present. Fundoplication may be limited to 180–280° posterior wrap (Toupet)

CO2 insufflation

 


240° semi-fundoplication

Antibiotics

Cefazolin 1–2 g iv

VTE prophylaxis

Heparin 5,000 units sq

 

Surgical time

1–2 h

Closing considerations

Inspect spleen for bleeding

EBL

100–150 mL

50 mL

100–150 mL

100–200 mL

Postop care

PACU → ward

ICU × 1–2 d

Mortality

< 0.5%

Morbidity

Recurrent hernia: 20%
Gas-bloat syndrome: 10–20%
Temporary dysphagia: 5–10%
Gastric fistula: < 2%





< 5%
5%




2%

Pain score

6–8

2–4

7–8

7–9

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Patient Population Characteristics

Age range

46–60 yr

Male:Female

1:2

Incidence

Not uncommon

Etiology

Esophagogastric reflux (100%); esophageal hiatus hernia (80–90%)

Associated conditions

Diverticulosis of colon (30–35%); cholelithiasis (25–30%)

Anesthetic Considerations

See Anesthetic Considerations for Esophageal Surgery following Esophagectomy, p. 482.

Suggested Readings

  1. Belsey R: Mark IV repair of hiatal hernia by the transthoracic approach. World J Surg1977; 1(4):475–81.
  2. Cuschieri, A: Laparoscopic antireflux surgery and repair of hiatal hernia. World J Surg1993; 17(1):40–5.
  3. Wong AS, Myers JC, Jamieson GG: Esophageal pH profile after laparoscopic total fundoplication compared to anterior fundoplication. J Gastrointest Surg2008; in press.

Esophagectomy

Surgical Considerations

Description: Esophagectomy is most commonly performed for malignant disease of the middle and lower 3rd of the esophagus and gastric cardia. This procedure also may be indicated for intractable benign stricture, Barrett's esophagus with high-grade dysplasia, and end-stage achalasia. There are several surgical options for esophageal resection, including the Ivor Lewis approach, which involves a laparotomy and right thoracotomy; the transhiatal approach, whereby the esophagus is mobilized through abdominal and neck incisions, and the left thoracoabdominal approach (Fig. 7.1-7). Although there are advantages and disadvantages to each, the final result is to use a portion of the stomach to replace the esophagus. In all approaches, the stomach is mobilized while preserving its blood supply from the right gastroepiploic and gastric arteries. The stomach is then transposed into the chest and a gastroesophageal anastomosis is fashioned either in the chest (Ivor Lewis and left chest approaches) or in the neck (transhiatal approach). To avoid delayed gastric emptying, a pyloroplasty or pyloromyotomy is often added, as is placement of a temporary jejunal feeding tube. Regardless of the surgical technique, patients with larger or locally advanced tumors may have received preoperative chemotherapy or radiation. In these patients, the combination of less distinct tissue planes and radiation-induced inflammation tends to lead to increased bleeding and/or increased insensible fluid losses.

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The previously mentioned variants of esophagectomy all involve use of the stomach as an esophageal replacement. When the stomach is not available (as with prior resection or caustic injury), the colon can be used as an esophageal substitute. Both the left and right colon can be used, with the vascular supply to the grafts based on either the ascending branch of the left colic artery or the right colic artery. Colon interpositions typically have higher complication rates than esophagectomies using gastric conduits.

Usual preop diagnosis: Carcinoma of esophagus or gastroesophageal junction; Barrett's esophagus; benign strictures

Summary of Procedures

 

Ivor Lewis

Transhiatal Esophagectomy

Thoracoabdominal

Total Esophagectomy + Colonic Interposition

Position

Supine and left lateral decubitus

Supine

Right lateral decubitus

Supine and right lateral decubitus

Incision

Midline abdominal + right chest and/or cervical incisions

Cervical and midline abdominal

Thoracoabdominal across costal margin (see Fig. 7.1-8)

Midline + right thoracic and cervical

Unique considerations

DLT

None

DLT

Antibiotics

Cefoxitin 2 g iv preop

VTE prophylaxis

Heparin 5,000 units sq

Surgical time

3–4 h

4–5 h

3–4 h

5–6 h

Closing considerations

Lung reexpansion

Pneumothorax

Lung reexpansion

Vascular integrity of colonic interposition

EBL

300–800 mL

Postop care

ICU × 1–2 d

ICU × 2–3 d

Mortality

5–10%

10%

Morbidity

Respiratory complications: 15–20%
Anastomotic leakage: < 5%
Anastomotic stricture: < 5%
Wound infection: < 5%


5–10%


< 5%


10%
10%

Pain score

7–9

6–8

7–9

7–9

Patient Population Characteristics

Age range

4–80 yr

Male:Female

2:1 for carcinoma

Incidence

1–2% of malignant disease

Etiology

Alcohol and tobacco; dietary factors – hot spicy foods; lye burns

Associated conditions

Barrett's esophagus; hiatus hernia; reflux esophagitis; radiation esophagitis; caustic burns

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Figure 7.1-7. Standard thoracoabdominal esophagosgastrectomy for carcinomas of the distal esophagus and cardia. A. Thoracoabdominal incision. B. Tissue to be resected (darker area). C. Completed reconstruction after intrathoracic esophagogastric anastomosis and either pyloromyotomy or pyloroplasty to prevent postvagotomy pylorospasm. (Reproduced with permission from Greenfield LJ, Mulholland, MW, Oldham KT, et al, eds: Surgery: Scientific Principles and Practice, 3rd edition. Lippincott Williams & Wilkins, Philadelphia: 2001).

Suggested Reading

  1. Orringer MB: Resection of the esophagus. In: General Thoracic Surgery,5th edition. Shields TW, LoCicero J III, Ponn RB, eds. Lippincott Williams & Wilkins, Philadelphia: 2000, 1697–722.

Anesthetic Considerations For Esophageal Surgery

(Procedures covered: esophagostomy; esophageal diverticulectomy; closure of esophageal perforation; esophagomyotomy; esophagogastric fundoplasty; esophagectomy; colonic interposition)

Patients presenting for esophageal surgery typically are those with carcinoma, motility disorders, strictures, hiatal hernia, reflux esophagitis, diverticula, and perforation. Patients tend to be elderly, with a history of tobacco abuse

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and alcohol consumption, and may have associated cardiopulmonary disease. Obesity and ischemic heart disease are increasingly frequent comorbid conditions. Esophageal disorders such as hiatal hernia, Barrett's esophagus, and carcinoma with incomplete obstruction predispose the patient to recurrent aspiration pneumonitis from intermittent reflux of gastric contents. Patients with esophageal diverticula, stricture, achalasia, and carcinoma with obstruction may present with retained food and oral secretions. Therefore, patients may need to be considered nonfasted.

 

Figure 7.1-8. Standard thoracoabdominal esophagogastrectomy for tumors of the upper and middle 3rd of the thoracic esophagus. A. Either a continuous thoracoabdominal incision or separate thoracic and abdominal incisions are used. B. Portion of esophagus to be resected (darker area). C. Completed reconstruction with high intrathoracic esophagogastric anastomosis and gastric drainage procedure. (Reproduced with permission from Greenfield LJ, Mulholland, MW, Oldham KT, et al, eds: Surgery: Scientific Principles and Practice, 3rd edition. Lippincott Williams & Wilkins, Philadelphia: 2001.)

Preoperative

Respiratory

Many patients with esophageal cancer have a long history of smoking resulting in COPD. Mediastinal lymphadenopathy and tumors of the upper esophagus may lead to tracheal/bronchial compression or erosion that may be revealed by CT and bronchoscopy. A history of gastric reflux and recurrent aspiration pneumonia → ↓ pulmonary reserve and ↑ risk of regurgitation/aspiration during anesthetic induction. (See Premedication, below.) If thoracotomy is a part of the procedure, the patient should be evaluated to ensure that OLV will be tolerated (see below). Determine if patient has been exposed to radiation and chemotherapeutic agents that may cause pulmonary fibrosis. Some agents, such as Bleomycin, may cause pulmonary toxicity (above a total dose of 300 U/m2) that is worsened by high concentrations of O2, which should be avoided during the perioperative period.
Tests: Consider PFTs (FEV1, FVC, DLCO), ABG, and flow-volume loops, if indicated by H&P. They can be helpful in predicting the likelihood of perioperative pulmonary complications and the possible need for postoperative ventilatory support. Patients with baseline hypoxemia/hypercarbia on room air have a greater likelihood of postop complications and ventilatory insufficiency. Severe restrictive or obstructive lung disease also will increase the chance of pulmonary morbidity in the periop period. A-P, lateral CXR (if suggestive of tracheal compression obtain MRI/CT).

Cardiovascular

Elderly patients may have coexisting CAD. In the setting of a recent angioplasty/stent, continued management with antiplatelet agents (clopidogrel) may preclude the use of epidural techniques. Patients may be hypovolemic and malnourished from dysphagia or anorexia. Preop chemotherapy treatment with agents such as doxorubicin may cause acute dysrhythmias and chronic cardiomyopathy (seen in 10% of patients if total dose is > 550 mg/m2). Some esophageal tumors are related to alcohol consumption and chronic abuse may produce a toxic cardiomyopathy. Preop optimization of cardiac status is important.
Tests: ECG to r/o dysrhythmias, myocardial ischemia, or prior MI. ECHO or dobutamine stress ECHO will provide important functional information about the heart at rest or under stress, respectively. Reversible ischemia and significant cardiomyopathy should prompt further cardiac consultation.

Hematologic

Tests: CBC with differential.

Laboratory

PT & PTT, basic metabolic profile and tests as indicated from H&P.

Premedication

Consider midazolam 1–2 mg iv. Consider H2-antagonists (e.g., ranitidine 50 mg iv), metoclopramide (10 mg iv 1 h preop), and Na citrate (30 mL po 10 min preop) in patients with reflux and partial obstruction. Patients with esophageal motility disorders, strictures/tumors with complete obstruction may not tolerate oral antacids.

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Intraoperative

Anesthetic technique: GETA (with or without epidural for intraop/postop analgesia). If the patient is clinically hypovolemic, restore intravascular volume before epidural placement and induction of GA. Surgeries involving only a cervical or endoscopic approach typically do not require epidural analgesia. If epidural analgesia is planned, placement and testing of the catheter before anesthetic induction is recommended. This is accomplished by injecting 5–7 mL of 1–2% lidocaine with 1:200,000 epinephrine via the epidural catheter and eliciting a segmental block. If a thoracic or thoracoabdominal approach is performed, placement of a DLT is indicated to provide OLV for optimal surgical conditions. (For additional discussion of DLT placement and OLV, see Anesthetic Considerations in Lobectomy, Pneumonectomy in Thoracic Surgery, p. 275.)

Induction

Patients with esophageal disease are often at risk for pulmonary aspiration; therefore, the trachea should be intubated after rapid-sequence induction with cricoid pressure. In cases with a difficult airway needing a DLT, placement of a single lumen tube should be accomplished (a) with the aid of a bougie, (b) via an LMA, or (c) with FOB. The single lumen tube is then changed to a DLT using a tube exchange catheter.

Maintenance

Standard maintenance (p. B-2), with or without N2O (for OLV). Alternatively, a combined technique may be used. A local anesthetic (e.g., 2% lidocaine with 1:200,000 epinephrine or 0.25% bupivacaine) can be infused or injected into a thoracic (3–5 mL) or lumbar (5–10 mL) epidural catheter to provide both anesthesia and optimal surgical conditions (contracted bowel and profound muscle relaxation). Continuous infusion of local anesthetic generally provides better hemodynamic stability than hourly bolus injections. To enhance the effect of epidural analgesia, a loading dose of opiates (e.g., hydromorphone 0.4–1 mg [thoracic] or 1–1.5 mg [lumbar]) can be administered early during the surgery and at least 1 h before conclusion of the case. Esophagectomy procedures can cause significant third-space losses; thus, maintenance of euvolemia with close monitoring of BP and UO. Esophageal procedures involving transient compression of the myocardium (i.e., thoracic approach for esophagomyotomy or esophagectomy) can induce dysrhythmias and/or ↓ BP. Monitoring of BP with an arterial catheter is recommended.

Emergence

Generally, tracheal extubation should be anticipated at the end of the case. The decision to keep the patient intubated postop depends on cardiopulmonary status and the site and extent of the surgical procedure. Patients with significant intraop fluid shift may develop airway edema that can → airway obstruction if extubated prematurely. This may also occur in operations involving high anastomoses in the neck. For those who may require prolonged postop ventilation, the DLT should be exchanged to a single-lumen ETT before transport to ICU. The use of an airway exchange catheter is safe, and direct laryngoscopy during the exchange prevents inadvertent seepage of blood or silent aspiration. Weaning from mechanical ventilation should begin when the patient is awake and cooperative, able to protect the airway, hemodynamically stable, and has adequate return of pulmonary function (as measured by VC > = 10 mL/kg; MIF of > 30 cmH2O; rapid, shallow breathing index of ≥ 100 [RR÷TV(L)]; respiratory rate < 25; and ABG that demonstrates adequate gas exchange).

Blood and fluid requirements

IV: 14–16 ga × l–2
NS/LR @ 8–12 mL/kg/h
Warm fluids
Consider T&C for 2–4 U PRBC

Plt, FFP, and cryoprecipitate (if required) should be administered according to lab tests (Plt count, PT, PTT, DIC screen, thromboelastography [TEG]). Maintain euvolemia based on estimates of blood loss, fluid shifts, fluids administered, and HR, BP, UO, base deficit, and invasive monitoring when em ployed.

Monitoring

Standard monitors (p. B-1)
Urinary catheter
± Arterial line
± CVP

CVP cannulation site determined by surgical approach. Attempt to prevent hypothermia during long operations. Consider forced-air warmer, heated humidifier, warming blanket, warming the OR, keeping patient covered until ready for prep, etc.

Positioning

If lateral decubitus position, use axillary roll, airplane arm holder
[check mark] pressure points, including ears, eyes, and genitals
[check mark] radial pulses to ensure correct placement of axillary roll (if misplaced, will compromise distal pulses).

Problems that can arise include brachial plexus injuries, damage to soft tissues, ears, eyes, genitals from malpositioning. Check down eye at frequent intervals.
Placing the oximeter probe on the down arm may assist in monitoring adequacy of perfusion.

Complications

Hypoxemia

Hypoxemia during OLV most commonly results from luminal obstruction (by blood or pulmonary secretions) of the DLT; [check mark] shunting, or malposition of DLT, which can move during surgical manipulation. Rx: suction DLT and [check mark] position; PEEP to ventilated lung (but may ↑ shunting); CPAP to nonventilated lung; return to double-lung ventilation. Temporary clamping of the PA (or inflate the balloon of the PA catheter, if available) may be necessary to improve shunting and oxygenation.

 

Hypercarbia
Dysrhythmia

Ensure adequate TV and RR.
[check mark] for mechanical compression of heart or great vessels. Check K+

 

Hypotension

[check mark] volume status and cardiac function. Consider neosynephrine for BP support if ↓ BP 2° epidural anesthetic. Maintaining an adequate BP is important for adequate perfusion and hence integrity of a newly formed anastomosis.

 

VTE Prophylaxis

See Appendix B

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Postoperative

Complications

Aspiration
Atelectasis

For patients at risk for atelectasis or aspiration, recover in the 45° head up or Fowler position (semi sitting)

 

Hemorrhage

For hemorrhage, [check mark] coags; replace factors as necessary

 

Pneumothorax
Hemothorax

Dx for pneumothorax and hemothorax: wheezing, coughing, dyspnea, ↓ PO2, ↓ PCO2. Confirm by CXR. Rx: chest tube drainage as necessary. In emergency (e.g., tension pneumothorax), use needle aspiration. Supportive Rx: O2, vasopressors, volume, ± ETT and IPPV

 

Hypoxemia
Hypoventilation

For hypoxemia and hypoventilation; Rx: adequate analgesia, minimize sedation, supplemental O2, may require IPPV

 

Recurrent laryngeal nerve injury

For laryngeal nerve injury, Dx: indirect visualization of vocal cords; patient usually will be hoarse

 

Esophageal anastomotic leak
VTE prophylaxis

Surgical repair Rx for esophageal anastomotic leak

 

SVT/AFib

Treat underlying cause and correct electrolyte abnormalities. Adenosine (6 mg iv, push and repeat to 12 mg iv) may be used for SVT. Most postop SVTs are 2° catecholamine surge. AFib may resolve spontaneously. Hemodynamically unstable patients will require cardioversion. β-blockers, amiodarone, Ca++ channel blockers, and overdrive cardiac pacing are effective in patients with stable AFib.

Pain management

Lumbar-thoracic epidural analgesia: hydromorphone (0.5–1.5 mg load, 0.1–0.3 mg/h infusion) + local anesthetic PCEA (p. C-3).

Patient should recover in ICU or hospital ward that is accustomed to treating side effects of epidural opiates (e.g., respiratory depression, hypotension, breakthrough pain, nausea, pruritus)

 

PCA

When an epidural cannot be used, a PCA with an opiate such as fentanyl or morphine/hydromorphone may be used for pain control.

 

NSAID

Ketorolac is helpful as adjuvant therapy for postop pain management.

Tests

CBC, basic metabolic profile,
ABG
CXR (r/o pneumothorax, atelectasis).

 

Suggested Readings

  1. Al-Rawi OY, Pennefather SH, Page RD, et al: The effect of thoracic epidural bupivacaine and an intravenous adrenalin infusion on gastric tube blood flow during esophagectomy. Anesth Analg2008; 106:884–7.
  2. Amar D: Cardiopulmonary complications of esophageal surgery. Chest Surg Clin N Am1997; 7(3):449–56.
  3. Cohen E, Neustein SM, Eisenkraft JB: Anesthesia for thoracic surgery. In: Clinical Anesthesia,5th edition. Barash, PG, Cullen BF, Stoelting RK eds. JB Lippincott Williams & Wilkins, Philadelphia: 2006, 813–55.
  4. Kahn L, Baxter FJ, Dauphin A, et al: A comparison of thoracic and lumbar epidural techniques for post-thoracoabdominal esophagectomy analgesia. Can J Anaesth1999; 46(5 Pt 1):415–22.

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  1. Kolker AC: Esophageal surgery. In: Cardiac, Vascular, and Thoracic Anesthesia.Youngberg JA, Lake CL, Roizen MF, Wilson RS, eds. Churchill Livingstone, Philadelphia: 2000, 688–702.
  2. Kucharczuk JC, Kaiser LR: Esophageal injury, diverticula, and neoplasms. In: Greenfield's Surgery: Scientific Principles and Practice,4th edition. Mulholland MW, Lillemoe KD, et al, eds. Lippincott Williams & Wilkins, Philadelphia: 2006, 691–708.
  3. Nagawa H, Kobori O, Muto T: Prediction of pulmonary complications after transthoracic oesophagectomy. Br J Surg1994; 81(6):860–2.
  4. Nichols FC, Allen MS, Deschamps C, et al: Ivor Lewis Esophagogastrectomy. Surg Clin N Am2005; 85: 583–92.
  5. Orringer MB, Orringer JS: Esophagectomy without thoracotomy: a dangerous operation? J Thorac Cardiovasc Surg1983; 85(1):72–80.
  6. Pennefather SH: Anesthesia for Oesophagectomy: Curr Opin Anaesthesiol2007; 20:15–20.
  7. Slinger PD, Hickey DR: The interaction between applied PEEP and auto-PEEP during one-lung ventilation. J Cardiothorac Vasc Anesth1998; 12(2):133–6.
  8. Smetana GW: Preoperative pulmonary evaluation. N Eng J Med1999; 340(1):937–44.