Mark F. Berry
Rebecca A. Schroeder
1. Esophagectomy is associated with considerable morbidity and mortality despite improvements in surgical technique and perioperative care.
2. The optimal technique in a particular patient depends on specific patient characteristics as well as surgeon- and center-specific experience and preference more than tumor morphology or staging.
3. Multimodal anesthetic management utilizing thoracic epidural analgesia, protective ventilation, prevention of tracheal aspiration, and judicious fluid management helps reduce postoperative morbidity, particularly pulmonary complications and anastomotic leakage.
A 65-year-old male patient who presents with advanced Barrett esophagus is scheduled to undergo an esophagectomy. He has a long standing history of gastroesophageal reflux, a 20 pack-year history of smoking and consumes 2 to 4 drinks per night.
His only medication is omeprazole.
Vital signs: BP 140/80, HR 80, RA SpO2 94%.
Laboratory examination is notable only for marginally elevated AST and ALT. An exercise-stress echocardiogram was normal.
Esophageal cancer is the most common indication for esophagectomy. The incidence of esophageal cancer is increasing and the epidemiology is changing such that adenocarcinoma, which is linked to obesity and gastroesophageal reflux disease, is now more common than squamous cell carcinoma. Mortality following esophagectomy has decreased but still exceeds that of most surgical procedures and long-term survival remains poor. Consequently, it is of critical importance to minimize perioperative morbidity in any manner possible. Esophageal resection can be performed via several different techniques, with the most appropriate technique for any specific individual patient being dependent on both patient and surgeon factors.
With less than 14,000 new cases annually in the United States, esophageal cancer is relatively uncommon. However, its incidence is steadily increasing and its epidemiology is changing significantly.1-3Recent evidence indicates that the incidence among white males has almost doubled while the incidence among blacks has decreased by almost 50%.1
Esophageal cancers are differentiated by histologic type and location, but also have many features in common. More than 90% of esophageal cancers in the United States are either adenocarcinomas (57%) or squamous cell carcinomas (37%).1,3 The distribution of tumor types varies according to race: 64% cases in whites are adenocarcinomas, while among the black population, 82% are of squamous cell origin.1 Tobacco use and a history of mediastinal radiation are risk factors for both tumor types. Other risk factors for adenocarcinoma include gastroesophageal reflux disease (GERD), obesity, and Barrett esophagus. Barrett esophagus with high-grade dysplasia is considered a premalignant condition as 50% are found to harbor occult malignant disease at the time of biopsy.4 Additional risk factors for squamous cell carcinoma are conditions that cause chronic esophageal irritation and inflammation such as alcohol abuse, achalasia, esophageal diverticuli, and frequent consumption of extremely hot beverages.2 Tumor location also distinguishes these two common cell types. Approximately three quarters of all adenocarcinomas are found in the distal esophagus, whereas squamous-cell carcinomas are more evenly distributed throughout the distal two-thirds.2 Survival rates are similar for patients with either adenocarcinoma or squamous cell carcinoma regardless of treatment modality, suggesting that both cell types share significant physiologic and cellular features.5 Overall 5-year survival for patients with esophageal cancer remains poor, although some improvement has been achieved with an increase from 5% to 17% over the last four decades.1
Clinical Presentation and Workup
The most common presenting symptoms of esophageal cancer are dysphagia (74%) and weight loss (57%) with less common symptoms being heartburn, odynophagia, shortness of breath, chronic cough, hoarseness, and hematemesis.6 The physical examination is usually unremarkable.2 A contrast study of the upper gastrointestinal (GI) tract is usually the initial diagnostic study and typically shows a stricture or ulceration when malignancy is present. Upper GI endoscopy is usually part of the initial workup and often shows a friable, ulcerated mass, which is then biopsied for pathologic examination. A computed tomographic (CT) scan of the chest, abdomen, and pelvis with intravenous contrast should be obtained when esophageal cancer is detected to evaluate for distant metastatic disease. Positron-emission tomography scans improve staging and will detect previously unsuspected metastatic disease in up to 15% of patients.7 The extent of loco-regional disease is defined by the depth of tumor invasion and the extent of lymph-node involvement, and may be evaluated with endoscopic ultrasound.2
STAGING AND PROGNOSIS
Staging of esophageal cancer has been defined by the American Joint Committee on Cancer Staging System, 6th edition. This system establishes tumor-node-metastasis (TNM) subclassifications in which the primary tumor (T) is defined by depth of invasion (Figure 17–1), lymph node involvement (N) is defined as present or absent, and extent of metastatic disease (M) is noted as none, regional or distant. The current system is described in Tables 17–1A and 17–1B.8 The likelihood of nodal metastases is almost zero in TIS lesions, but increases with increasing depth of invasion and as many as 50% patients with T1 lesions will have lymph node involvement.9,10 At the time of diagnosis, approximately 50% of patients have evidence of distant metastatic disease.1,2
Figure 17–1. Definition of T stage for esophageal cancer.
Table 17–1A. Esophageal Cancer Staging: Definitions
Table 17–1B. Esophageal Cancer Staging: Classification System
Survival is related to the stage at diagnosis and subsequent treatment. Current short- and long-term survival rates are listed in Table 17–2.1,2 In general, patients who undergo complete resection of their cancer have a 5-year disease-free survival of 32%, while for patients with residual disease following surgical resection, overall survival is less than 5%.11
Table 17–2. Surgical Treatment of Esophageal Cancer and Long-Term Outcomes
Choice of treatment for esophageal cancer depends heavily on stage and tumor location. However, as outcomes remain poor with all strategies, most remain somewhat controversial and an area of active research.12 Treatment options include local mucosal therapies, esophagectomy, chemotherapy, and radiation therapy. Mucosal treatments such as endoscopic mucosal resection, photodynamic therapy, or radiofrequency ablation are considered for patients with carcinoma in situ or high-grade dysplasia but are not appropriate for patients with stage-T1 (or greater) disease due to the likelihood of lymph node involvement. For patients with stage I-III disease who receive surgical treatment, 5-year survival is 28%, compared to 10% for those treated medically.13 Therefore, primary nonsurgical treatment should be reserved for those who refuse surgery, have unresectable tumors, or are not thought to be surgical candidates for other reasons. Patients with distant metastatic disease (M1b) generally receive palliative treatment with chemotherapy and possibly radiation. To summarize, esophagectomy with chemotherapy and radiation therapy as possible adjuncts should be considered for all patients other than those who are stage T0 or IVb.
Most patients with T1-2 (stage I-II) esophageal cancer without lymph node involvement undergo surgery without other preoperative treatment.14 Patients with T3, N1, and M1a (stage III or IVa) disease who are resection candidates are considered for induction therapy and then surgery. Use of either induction chemotherapy or radiation alone followed by surgery does not improve survival compared with surgery alone.11,15,16 However, patients who receive induction chemotherapy and radiation therapy followed by surgery may have a modest survival advantage compared with surgery alone.12,17-20Postoperative radiation alone may reduce the incidence of local recurrence in those patients who have residual tumor after resection but is not beneficial in the absence of residual disease.2,21,22Postoperative chemotherapy has not been shown to have an additive effect on survival compared with surgery alone, although additional therapy may be warranted in patients who have a high likelihood of metastatic disease based on a large number of tumor positive nodes.23
Techniques of Esophagectomy
Resection of the esophagus for malignancy is a very complex procedure. The esophagus traverses three body regions or cavities and the anatomy of the esophagus in the posterior mediastinum is such that its accessibility is very different at different positions in the chest. In addition, an appropriate conduit must be prepared in order to reestablish gastrointestinal continuity, and this conduit must be placed in a location such that its blood supply will remain viable. Esophageal resection generally requires access to at least two body cavities, and often requires at least two incisions and patient repositioning intraoperatively. Structures at significant risk include the spleen, trachea, and main stem bronchi as well as major vascular structures in the chest.
The most common surgical techniques used for esophagectomy are listed in Table 17–3. Minimally invasive techniques with either laparoscopy and/or thoracoscopy have been reported for most approaches (except the left thoracoabdominal approach). The final approach chosen for a particular patient depends on surgical experience and preference, institutional tradition and patient characteristics. Relevant factors include stage of disease, associated lesions such as Barrett esophagus or achalasia, other medical comorbidities, pulmonary function, and previous surgical history. In general, a proximal and distal disease-free margin of at least 5 cm should be achieved; thus, the location of the tumor is a critical factor in determining the surgical approach.12,24 Also, as the total number of lymph nodes involved and removed is an important predictor of survival, the transthoracic approaches may be preferred over others that do not provide equivalent access to the relevant nodes.23,25-27
Table 17–3. Characteristics of the Different Esophagogastrectomy Procedures
Surgeons overwhelmingly choose to use the stomach as the final conduit and the majority of these patients have good or excellent functional results.28 On the other hand, the colon may be the conduit of choice if the patient has had prior gastric surgery or another disqualifying condition such as diabetic gastroparesis. Its use carries similar morbidity and mortality and provides good long-term eating capability.29,30
The optimal location for the esophageal anastomosis after resection (cervical versus intrathoracic) is controversial, although almost 60% are placed in the cervical region.28 The advantages of a cervical anastomosis include better access for a wider primary esophageal resection, avoidance of highly morbid thoracotomy incisions, and less severe postoperative symptoms of reflux.12,31 Conversely, advantages of an intrathoracic anastomosis include a lower incidence of anastomotic leak and injury to the recurrent laryngeal nerves as well as a lower risk of postoperative stricture formation.12,31,32 In the current era, mortality associated with cervical and intrathoracic leaks is similar, although intrathoracic leaks are more likely to require surgical intervention.12,31,33,34
Specifics for each surgical technique are described below with advantages and disadvantages listed in Table 17–4. In general, all patients undergo preoperative upper endoscopy to confirm tumor location prior to resection; patients with tumors in the mid-esophagus should have bronchoscopy to rule out airway involvement. A nasogastric (NG) tube should be placed prior to the start of the procedure to assist with esophageal mobilization and is manipulated during the procedure as requested and guided by the surgical team. Also, a jejunostomy feeding tube is placed at the end of the procedure, as there is often a delay in the return of normal eating during the postoperative period.
Table 17–4. Advantages and Disadvantages of Specific Esophagogastrectomy Procedures
THREE-INCISION ESOPHAGECTOMY (MCKEOWN)
The three-incision esophagectomy or modified McKeown approach combines left cervical, right thoracic, and abdominal incisions (Figure 17–2A). This approach is especially useful for tumors of the mid and upper esophagus and for tumors where a long Barrett segment is present. The patient is initially positioned in the left lateral decubitus position for a right thoracotomy or thoracoscopy. One-lung ventilation (OLV) is instituted for the thoracic portion of the case. The esophagus is mobilized from the thoracic inlet to the esophageal hiatus and a lymph node dissection performed. Azygous vein and recurrent laryngeal nerve injury are significant risks during this portion of the procedure. The thoracic incisions are closed after placement of a chest tube and the patient is repositioned in the supine position with a roll under the scapula to extend the neck, and the head turned to the right to maximally expose the left neck. An upper midline laparotomy or laparoscopy is then performed and the esophageal hiatus is mobilized.
Figure 17–2. Incisions used for esophagectomy. A. Three-Incision; B. Transhiatal; C. Ivor-Lewis; D. Left Thoracoabdominal.
The third and final incision, a left cervical incision, is then made and the cervical esophagus is dissected free in the neck. The recurrent laryngeal nerve is again at significant risk at this point. The nasogastric tube is partially withdrawn and the cervical esophagus is divided. A suture or a rubber drain is fastened to the distal end of the divided esophagus and the distal esophagus is withdrawn through the esophageal hiatus into the abdominal incision. The prepared gastric conduit is then pulled back through the hiatus and up into the neck with care to avoid torsion. The cervical anastomosis is then performed and the NG tube is guided through the anastomosis under direct supervision by the surgical team.
The transhiatal esophagectomy combines left cervical and abdominal incisions. (Figure 17–2B) This approach is probably ideal for patients with Barrett and high-grade dysplasia where lymph node dissection is not as critical for staging purposes. The abdominal portion of this procedure is performed as described above for the three-incision technique. The hiatus is dilated, and the surgeon’s hand is inserted into the mediastinum to bluntly dissect the esophagus free from other intrathoracic structures. A cervical incision is then made, and the esophagus is dissected in a similar manner from the neck into the chest but with special care to avoid injury to the recurrent laryngeal nerve. After complete esophageal mobilization, the esophagus is divided and the anastomosis is performed in the neck as described above for the three-incision technique.
The Ivor-Lewis esophagectomy resembles the modified McKeown approach, but involves only two incisions: right thoracic and upper abdominal. (Figure 17–2C) Although it also requires OLV, the Ivor Lewis begins with the patient in the supine position for laparotomy or laparoscopy for preparation of the gastric conduit. The gastric tube is then advanced into the chest as far as possible and the abdomen is closed. The patient is then repositioned in the left lateral decubitus position for right thoracotomy or thoracoscopy. In the chest, the esophagus is mobilized and divided. The gastric conduit is pulled further into the chest and the anastomosis performed. The thoracotomy or thoracoscopy incisions are closed after placement of a chest tube.
LEFT THORACOABDOMINAL ESOPHAGECTOMY
The left thoracoabdominal approach can be performed with acceptable morbidity and mortality, but is only considered for patients with tumors limited to the distal esophagus, and even in those cases is associated with high rates of residual disease.35 This approach necessitates OLV, and the patient is positioned in the right lateral decubitus position but with the abdomen rolled back approximately 45°. A thoracoabdominal incision is made along the 7th intercostal interspace across the costal margin, and the diaphragm is taken down circumferentially from the chest wall (Figure 17–2D). Esophageal and gastric mobilization and resection are performed as described for the Ivor-Lewis technique but with reconstruction of the diaphragm prior to closure.
Anesthetic Management for Esophagectomy Procedures
Anesthetic care is an important component of the multidisciplinary approach to management of esophagectomy patients that has been shown in clinical studies to improve perioperative. Good results have been achieved with multimodal care plans utilizing thoracic epidural analgesia, early extubation, early mobilization, and a restrictive approach to fluid management.36,37 Other anesthetic concerns include preoperative assessment, the need for OLV, management of intraoperative events including dysrhythmias, hemorrhage and airway injury, and use of protective ventilation strategies. In addition, it is important to be aware of the specific surgical plan, as each approach to esophagectomy has its own requirements and implications for the anesthesia care team.
In general, patients presenting for esophagectomy for malignant disease have significant comorbidities and these will guide preoperative assessment and the need for invasive monitoring to a greater degree than the procedure itself. Invasive arterial blood pressure monitoring is routinely used both for blood gas sampling during OLV and for continuous blood pressure measurement during procedures that may involve significant dysrhythmias or sudden changes in cardiac output or blood loss. Central venous pressure monitoring is not routinely used, but if necessary, should be placed in the great veins on the right-hand side in cases in which a cervical anastomosis is planned.
Prior to surgical incision, an NG tube should be placed and left either to intermittent low suction or to gravity drainage. In cases of an obstructing lesion, most surgeons will still request an NG tube be placed in the proximal esophagus to assist with the cervical dissection. As discussed above, prior to stapling or dividing the distal esophagus, the NG tube should be withdrawn either into the pharynx or as specifically directed by the surgical team, and then advanced through the esophageal anastomosis, again under direct surgical supervision. When the tube is in final position, it should be firmly secured to avoid displacement during extubation or patient transfer or movement. It is also helpful to place a reference mark on the tube itself so that it can be easily determined if its position has changed.
Airway, Ventilation, and Extubation
As noted above, all surgical approaches to esophagectomy other than transhiatal require OLV, and this can be accomplished with a bronchial blocker or use of a double-lumen endotracheal tube. Esophagectomy surgery is marked by a significant inflammatory response, and as such, lung protective strategies may contribute to decreasing postoperative pulmonary morbidity.38,39 While it is also true that very low-volume ventilation also causes lung injury, esophagectomy patients ventilated with a tidal volume of 5 mL/kg during OLV had lower indices of inflammation and were extubated earlier than those who received 9 mL/kg.39 It seems prudent therefore to continue to recommend a reduced tidal volume, in line with current thinking on lung protection strategies. In addition, peak and plateau inspiratory pressures should be minimized as much as possible and inspired oxygen concentration should be kept as low as possible to avoid oxygen toxicity (this is particularly important in patients who have received induction chemotherapy) as well as to minimize the remote risk of fire in the event of an airway injury.40
Timing of extubation has been a point of controversy in recent times. In the past, it was routine practice to leave patients intubated following esophagectomy to avoid the possibility of trauma to the anastomosis should reintubation become necessary. However, more recent retrospective reviews support immediate extubation.41,42 In these series, use of thoracic epidural analgesia and restrictive fluid management have been associated with successful early extubation. Conversely, other studies have suggested increased mortality rates in patients who were extubated early.43 However, it seems that early extubation is safe when it is part of a management plan that involves early mobilization, pulmonary toilet and optimal analgesia.41
Strategies guiding perioperative fluid management must balance the maintenance of perfusion pressure and oxygen delivery to vital organs and the intended surgical conduit while at the same time avoiding peripheral and pulmonary edema.40 Erring to either extreme is problematic, as hypovolemia results in hypoperfusion of the mesentery, while fluid overload impairs anastomosis and wound healing, and exacerbates cardiac or respiratory dysfunction.
Debates have raged for decades over the optimal amount and type of fluid to administer. Recent investigations have suggested that relative crystalloid restriction may improve outcome in major gastrointestinal surgery.44-47 Furthermore, fluid restriction has been part of several multimodal management strategies that have been successful in decreasing pulmonary morbidity.41,48 However, difficulty arises from the fact that there is no common definition for exactly what constitutes “restrictive.” Goal-directed therapy using noninvasive measures of cardiac output has been successfully employed for abdominal surgery, but has not been specifically investigated for esophageal resection.49,50 Nevertheless, attempts to synthesize what data do exist seem to warrant the conclusion that, in general, liberal strategies contribute to less positive outcomes, but that goal-directed therapy may be better than either an empiric liberal or restrictive approach.
Cardiac dysrhythmias occur in up to 65% patients undergoing esophagectomy.51,52 These occur most commonly during transhiatal procedures during the blunt dissection portion of the case and are well-tolerated most of the time. Most are atrial tachydysrhythmias, but more than 50% of these are of combined atrial and ventricular origin. Interestingly, in a closely monitored observational study, there was no correlation between the incidence of dysrhythmias and that of hypotension, but there was a strong correlation between hypotension and the duration of manipulation.51
Other serious intraoperative events that must be considered are the risks of hemorrhage and airway injury. While massive bleeding is rare, it may require rapid conversion from a minimally invasive to an open technique, or even an emergent change in patient position to facilitate surgical exposure of the involved vessel. In general, if severe bleeding occurs in the mid- or upper-esophagus, it may require conversion to a right thoracotomy for approach to the azygous vein, and if from the lower third of the esophagus, a left thoracotomy may be required to access a bleeding esophageal branch from the aorta. Fortunately, such vascular injuries occur in less than 2% of transhiatal esophagectomy cases.53 Similarly, airway injury is rare (<1% cases) and often minor.54 These injuries are mostly limited to the distal membranous trachea or proximal bronchi, and are usually detected by the smell of inhaled anesthetic in the field or a feeling of airflow by the surgeon with each ventilator-delivered breath. It is rare that an injury is large enough to be detected by loss of ventilator volume unless very low-fresh gas flows are being used. If an airway injury is detected, it may require deflation of the endotracheal tube cuff and advancement of the tube past the injury with manual guidance by the surgeon. If the injury is large, a right thoracotomy may be required to access the carina for surgical repair. In any case of airway injury, it is crucially important to extubate the patient immediately postoperatively and avoid reintubation to prevent pressure on or manipulation of the suture line.
Adequate pain control is of paramount importance in augmenting postoperative recovery and rehabilitation following esophagectomy and there is evidence as well as general consensus that thoracic epidural analgesia (TEA) is the optimal technique to achieve this. In addition to superior pain control, TEA may also exert a positive effect on immune function and the stress response to surgery, decrease pulmonary complications, and decrease the risk of anastomotic leak.55 Indeed, lack of TEA has been associated with increased morbidity and an increased risk of developing post-thoracotomy pain syndrome.56 However, a systematic review has indicated that paravertebral blocks may also be a good choice for esophagectomy patients and may have a lower incidence of side effects.57
Immediate and Long-Term Outcomes Following Esophagectomy
Even with advances in surgical technique, anesthetic and critical care, esophagectomy continues to be a source of significant morbidity and mortality in both the immediate perioperative period and for long-term survivors. Estimates of perioperative mortality range from 8.8% to 14% with major and total morbidity measured at 25% and 50%, respectively.6,15,31,33,58-68 Patients undergoing esophageal surgery have long hospital stays and prolonged overall recovery periods, and this is more than double when significant complications occur.31,62,64,69 It is perhaps for these reasons that surgery is pursued for only 34% potentially resectable stage I, II, and III esophageal cancers.13
Interestingly, clinical studies have shown that surgical and center experience is much more important in determining ultimate outcome than choice of procedure. Prospective trials have failed to demonstrate any significant differences in short- or long-term survival or quality of life between transthoracic and transhiatal esophagectomies, although some evidence suggests that the transhiatal approach has a slightly lower rate of perioperative complications and these patients may achieve better activity levels postoperatively.59-61,69-71 However, centers and surgeons that perform high volumes of esophageal surgery report mortality rates that are significantly lower for both transhiatal and transthoracic procedures than those reported in multicenter studies or national databases.12,15,31,72,73 In fact, it appears that the mortality rate for low versus high volume centers and surgeons may differ by as much as 50%. Interestingly, high volume is defined as greater than 12 or 5 cases/year for centers and surgeons respectively, and low volume as less than 5 or 2 cases/year, again for centers and surgeons, respectively.61,74-76 Similarly, improvements reported in long-term surgical outcomes are significantly better for high volume centers and surgeons, with some centers reporting recent mortality rates as low as 1%.15,62,72,77-80 Specialty training also appears to have a significant effect on outcome, with surgeons without specialty training having 37% to 50% higher mortality than those with specialty training.64,74,81
Minimally invasive esophagectomy can be performed by experienced surgeons with low conversion rates and a median reported hospital stay of 7 days.65,82 These techniques may result in less morbidity and mortality and shorter postoperative recovery times, but they continue to have initially longer operative times, and morbidity and mortality rates as high as 46% and 6%, respectively.67,82,83 The improved results seen with minimally invasive techniques are probably due not only to the differences in surgical approach, but also to the fact that they are being performed by experienced and highly trained esophageal surgeons at high volume centers.
Morbidity Following Esophagectomy
A summary of complications following esophagectomy is listed in Table 17–5. Risk factors for major morbidity are pulmonary disease, older age, black race, congestive heart failure, coronary artery disease, peripheral vascular disease, malnutrition, decreased functional status, hypertension, insulin-requiring diabetes, higher American Society of Anesthesiology Physical Status Classification, and use of tobacco or steroids.58,60,64 Preoperative predictors of mortality based on multivariable analysis include higher Charlson score (a measure of comorbid conditions), older age, renal dysfunction, diabetes, alcohol abuse, decreased functional status, intraoperative transfusion, and ascites.58,63 Tumor location and histology are also important, with squamous cell carcinomas and upper third esophageal tumors being associated with worse outcomes.84,85 As noted above, undergoing surgery at a center where less than 12 esophagectomies are performed per year is also a risk factor for postoperative mortality.63Finally, neoadjuvant therapy has been variably identified as a predictor of significant morbidity and mortality in the postoperative period.58,64
Table 17–5. Perioperative Complications Following Esophagogastrectomy6,15,31,33,58-61,64-68,86,87
Considering the overall poor prognosis for esophageal cancer patients, the impact of surgical complications on survival and quality of life cannot be overstated.12,88 However, surgical technique and perioperative care have implications beyond immediate perioperative survival. Improved long-term survival and quality of life are often directly related to avoidance of postoperative complications.89Measures that have been successful in reducing perioperative morbidity include aggressive preoperative conditioning, minimizing intensive care unit stay, aggressive pain management, early ambulation, involvement of a dedicated intensivist in the perioperative care team and an overall multidisciplinary, multimodal approach to management.15
Anastomotic Complications: Stricture and Leak
Anastomotic leaks occur in 6% to 14% patients following esophagectomy surgery and have traditionally been associated with extremely high mortality. However, with improvements in surgical technique and critical care, mortality rates as low as 3.3% have been achieved.33,90,91 Clinical features commonly associated with leaks include fever, leukocytosis, pleural effusion, and sepsis, although small leaks are often identified in asymptomatic patients.92 Many leaks (57%) can be managed nonoperatively, although operative alternatives include stent placement, primary anastomotic repair, anastomotic tissue reinforcement (muscle flap), and esophageal diversion.93,94 Early leaks (within 5 days) and those associated with gastric tip necrosis (incidence 2%-3%) are most likely to require surgical treatment.91,92
Respiratory complications are the most common cause of death following esophagectomy.31 Risk of pneumonia appears to be highest in those approaches that involve a thoracotomy incision. Reducing pulmonary complications with the use of epidural analgesia and aggressive use of bronchoscopy for clearance of pulmonary secretions appears to reduce perioperative mortality.95 Other strategies include careful assessment of swallowing abnormalities and risk of aspiration by cineradiography or fiberoptic endoscopy before initiating oral intake.31
Chylothorax occurs in up to 9% patients who have undergone esophagectomy.68 Conservative management is not often pursued as this usually results in nutritional and immunologic depletion and an increased risk of infectious complications. Early intervention with thoracic duct ligation is generally successful and avoids these complications.96 Thoracic duct ligation in the course of a thoracic procedure may be considered as a prophylactic measure.
Vocal Cord Paralysis
The incidence of recurrent laryngeal nerve injury manifesting as early postoperative hoarseness is reportedly as high as 36% following esophagectomy. Such injuries also occur in 4.5% to 14% patients who have a cervical anastomosis.15,68 Hoarseness is generally transient and resolves in 2 to 12 weeks. Patients with persistent vocal cord paralysis require cord medialization procedures, as long-term persistent hoarseness is associated with debilitated performance status, as well as swallowing and pulmonary dysfunction.97 Patients with evidence of aspiration should undergo early cord medialization, as this has been shown to decrease the incidence of pneumonia and need for bronchoscopy.98
Anesthesia for Post-Esophagectomy Patients
It is not uncommon for a patient to require general anesthesia for additional procedures (eg, for anastomotic dilation) following esophagectomy. In such cases, it is crucial to remember that these patients are at significant risk for aspiration, and that aspiration, even when minor, can result in aspiration pneumonitis, lung abscess, or respiratory failure. (Figure 17–3) Post-esophagectomy patients should be managed with a rapid sequence technique with cricoid pressure when undergoing induction of general anesthesia. It is important to remember, however, that if the patient had a cervical anastomosis, the cricoid cartilage may no longer overlie the esophagus, and cricoid pressure may not, therefore, occlude its lumen. Minimizing the time period during which aspiration may occur is thus of the utmost importance. Also important is pharmacologic prophylaxis with a non-particulate antacid. Metoclopramide, H2-blockers and proton-pump inhibitors should also be considered. If aspiration occurs, patients should undergo immediate bronchoscopy with suction removal of all visible evidence of aspirated material and lavage of the airways. Prophylactic use of antibiotics and steroids remains controversial. The planned surgical procedure should be cancelled (depending on the urgency of the case), and a minimum period of observation in a monitored setting is mandatory. If any respiratory symptoms develop, the patient should be admitted to an intensive care unit for observation.
Figure 17–3. Radiographic consequences of aspiration on induction of general anesthesia in post-esophagectomy patients. A. 83-year-old male patient s/p esophagogastrectomy developed new bilateral pulmonary opacities after aspirating on induction of general anesthesia for pulmonary decortication. B. 65-year-old male patient s/p esophagectomy who aspirated gastric contents on induction of general anesthesia for a partial nephrectomy and developed a right-sided lung abscess.
1. Horner M, Ries L, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2006, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2006/, based on November 2008 SEER data submission, posted to the SEER web site, 2009.
2. Enzinger PC, Mayer RJ. Esophageal cancer. N Engl J Med. 2003;349(23):2241-2252.
3. Pennathur A, Luketich JD. Resection for esophageal cancer: strategies for optimal management. Ann Thorac Surg. 2008;85(2):S751-S756.
4. Nigro JJ, Hagen JA, DeMeester TR, et al. Occult esophageal adenocarcinoma: extent of disease and implications for effective therapy. Ann Surg. 1999;230(3):433-438; discussion 438-440.
5. Chang DT, Chapman C, Shen J, Su Z, Koong AC. Treatment of esophageal cancer based on histology: a surveillance epidemiology and end results analysis. Am J Clin Oncol. 2009;32(4):405-410.
6. Daly JM, Fry WA, Little AG, et al. Esophageal cancer: results of an American College of Surgeons Patient Care Evaluation Study. J Am Coll Surg. 2000;190(5):562-572; discussion 572-563.
7. Downey RJ, Akhurst T, Ilson D, et al. Whole body 18FDG-PET and the response of esophageal cancer to induction therapy: results of a prospective trial. J Clin Oncol. 2003;21(3):428-432.
8. Greene FL, Page DL, Fleming ID, April F, eds. AJCC Cancer Staging Manual. 6th ed. New York: Springer-Verlag; 2003.
9. Nigro JJ, Hagen JA, DeMeester TR, et al. Prevalence and location of nodal metastases in distal esophageal adenocarcinoma confined to the wall: implications for therapy. J Thorac Cardiovasc Surg. 1999;117(1):16-23; discussion 23-15.
10. Rice TW, Zuccaro G, Jr, Adelstein DJ, Rybicki LA, Blackstone EH, Goldblum JR. Esophageal carcinoma: depth of tumor invasion is predictive of regional lymph node status. Ann Thorac Surg. 1998;65(3):787-792.
11. Kelsen DP, Winter KA, Gunderson LL, et al. Long-term results of RTOG trial 8911 (USA Intergroup 113): a random assignment trial comparison of chemotherapy followed by surgery compared with surgery alone for esophageal cancer. J Clin Oncol. 2007;25(24):3719-3725.
12. D’Amico TA. Surgery for esophageal cancer. Gastrointest Cancer Res. 2008;2(4 Suppl):S6-S9.
13. Paulson EC, Ra J, Armstrong K, Wirtalla C, Spitz F, Kelz RR. Underuse of esophagectomy as treatment for resectable esophageal cancer. Arch Surg. 2008;143(12):1198-1203; discussion 1203.
14. Ajani JA, Barthel JS, Bekaii-Saab T, et al. Esophageal cancer. J Natl Compr Canc Netw. 2008;6(9):818-849.
15. Orringer MB, Marshall B, Chang AC, Lee J, Pickens A, Lau CL. Two thousand transhiatal esophagectomies: changing trends, lessons learned. Ann Surg. 2007;246(3):363-372; discussion 372-364.
16. Arnott SJ, Duncan W, Gignoux M, et al. Preoperative radiotherapy for esophageal carcinoma. Cochrane Database Syst Rev. 2005(4):CD001799.
17. Graham AJ, Shrive FM, Ghali WA, et al. Defining the optimal treatment of locally advanced esophageal cancer: a systematic review and decision analysis. Ann Thorac Surg. 2007;83(4):1257-1264.
18. Fiorica F, Di Bona D, Schepis F, et al. Preoperative chemoradiotherapy for oesophageal cancer: a systematic review and meta-analysis. Gut. 2004;53(7):925-930.
19. Kaklamanos IG, Walker GR, Ferry K, Franceschi D, Livingstone AS. Neoadjuvant treatment for resectable cancer of the esophagus and the gastroesophageal junction: a meta-analysis of randomized clinical trials. Ann Surg Oncol. 2003;10(7):754-761.
20. Chirieac LR, Swisher SG, Ajani JA, et al. Posttherapy pathologic stage predicts survival in patients with esophageal carcinoma receiving preoperative chemoradiation. Cancer. 2005;103(7):1347-1355.
21. Fok M, Sham JS, Choy D, Cheng SW, Wong J. Postoperative radiotherapy for carcinoma of the esophagus: a prospective, randomized controlled study. Surgery. 1993;113(2):138-147.
22. Teniere P, Hay JM, Fingerhut A, Fagniez PL. Postoperative radiation therapy does not increase survival after curative resection for squamous cell carcinoma of the middle and lower esophagus as shown by a multicenter controlled trial. French University Association for Surgical Research. Surg Gynecol Obstet. 1991;173(2):123-130.
23. Peyre CG, Hagen JA, DeMeester SR, et al. Predicting systemic disease in patients with esophageal cancer after esophagectomy: a multinational study on the significance of the number of involved lymph nodes. Ann Surg. 2008;248(6):979-985.
24. Barbour AP, Rizk NP, Gonen M, et al. Adenocarcinoma of the gastroesophageal junction: influence of esophageal resection margin and operative approach on outcome. Ann Surg. 2007;246(1):1-8.
25. Peyre CG, Hagen JA, DeMeester SR, et al. The number of lymph nodes removed predicts survival in esophageal cancer: an international study on the impact of extent of surgical resection. Ann Surg. 2008;248(4):549-556.
26. Greenstein AJ, Litle VR, Swanson SJ, Divino CM, Packer S, Wisnivesky JP. Effect of the number of lymph nodes sampled on postoperative survival of lymph node-negative esophageal cancer. Cancer. 2008;112(6):1239-1246.
27. Wolff CS, Castillo SF, Larson DR, et al. Ivor Lewis approach is superior to transhiatal approach in retrieval of lymph nodes at esophagectomy. Dis Esophagus. 2008;21(4):328-333.
28. Enestvedt CK, Perry KA, Kim C, et al. Trends in the management of esophageal carcinoma based on provider volume: treatment practices of 618 esophageal surgeons. Dis Esophagus. 2010;23(2):136-144.
29. Cerfolio RJ, Allen MS, Deschamps C, Trastek VF, Pairolero PC. Esophageal replacement by colon interposition. Ann Thorac Surg. 1995;59(6):1382-1384.
30. Kolh P, Honore P, Degauque C, Gielen J, Gerard P, Jacquet N. Early stage results after oesophageal resection for malignancy—colon interposition vs gastric pull-up. Eur J Cardiothorac Surg. 2000;18(3):293-300.
31. Atkins BZ, Shah AS, Hutcheson KA, et al. Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg. 2004;78(4):1170-1176; discussion 1170-1176.
32. Okuyama M, Motoyama S, Suzuki H, Saito R, Maruyama K, Ogawa J. Hand-sewn cervical anastomosis versus stapled intrathoracic anastomosis after esophagectomy for middle or lower thoracic esophageal cancer: a prospective randomized controlled study. Surg Today. 2007;37(11):947-952.
33. Alanezi K, Urschel JD. Mortality secondary to esophageal anastomotic leak. Ann Thorac Cardiovasc Surg. 2004;10(2):71-75.
34. Urschel JD. Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review. Am J Surg. 1995;169(6):634-640.
35. Forshaw MJ, Gossage JA, Ockrim J, Atkinson SW, Mason RC. Left thoracoabdominal esophagogastrectomy: still a valid operation for carcinoma of the distal esophagus and esophagogastric junction.Dis Esophagus. 2006;19(5):340-345.
36. Brodner G, Pogatzki E, Van Aken H, et al. A multimodal approach to control postoperative pathophysiology and rehabilitation in patients undergoing abdominothoracic esophagectomy. Anesth Analg. 1998;86(2):228-234.
37. Low DE, Kunz S, Schembre D, et al. Esophagectomy—it’s not just about mortality anymore: standardized perioperative clinical pathways improve outcomes in patients with esophageal cancer. J Gastrointest Surg. 2007;11(11):1395-1402; discussion 1402.
38. Kooguchi K, Kobayashi A, Kitamura Y, et al. Elevated expression of inducible nitric oxide synthase and inflammatory cytokines in the alveolar macrophages after esophagectomy. Crit Care Med. 2002;30(1):71-76.
39. Michelet P, D’Journo XB, Roch A, et al. Protective ventilation influences systemic inflammation after esophagectomy: a randomized controlled study. Anesthesiology. 2006;105(5):911-919.
40. Ng JM. Perioperative anesthetic management for esophagectomy. Anesthesiol Clin. 2008;26(2):293-304, vi.
41. Lanuti M, de Delva PE, Maher A, et al. Feasibility and outcomes of an early extubation policy after esophagectomy. Ann Thorac Surg. 2006;82(6):2037-2041.
42. Yap FH, Lau JY, Joynt GM, Chui PT, Chan AC, Chung SS. Early extubation after transthoracic oesophagectomy. Hong Kong Med J. 2003;9(2):98-102.
43. Bartels H, Stein HJ, Siewert JR. Early extubation vs late extubation after esophagus resection: a randomized, prospective study. Langenbecks Arch Chir Suppl Kongressbd. 1998;115:1074-1076.
44. Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S, Matot I. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology. 2005;103(1):25-32.
45. Brandstrup B, Tonnesen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg. 2003;238(5):641-648.
46. Holte K, Foss NB, Andersen J, et al. Liberal or restrictive fluid administration in fast-track colonic surgery: a randomized, double-blind study. Br J Anaesth. 2007;99(4):500-508.
47. Joshi GP. Intraoperative fluid restriction improves outcome after major elective gastrointestinal surgery. Anesth Analg. 2005;101(2):601-605.
48. Kita T, Mammoto T, Kishi Y. Fluid management and postoperative respiratory disturbances in patients with transthoracic esophagectomy for carcinoma. J Clin Anesth. 2002;14(4):252-256.
49. Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth. 2002;88(1):65-71.
50. Button D, Weibel L, Reuthebuch O, Genoni M, Zollinger A, Hofer CK. Clinical evaluation of the FloTrac/Vigileo system and two established continuous cardiac output monitoring devices in patients undergoing cardiac surgery. Br J Anaesth. 2007;99(3):329-336.
51. Malhotra SK, Kaur RP, Gupta NM, Grover A, Ramprabu K, Nakra D. Incidence and types of arrhythmias after mediastinal manipulation during transhiatal esophagectomy. Ann Thorac Surg. 2006;82(1):298-302.
52. Sedrakyan A, Treasure T, Browne J, Krumholz H, Sharpin C, van der Meulen J. Pharmacologic prophylaxis for postoperative atrial tachyarrhythmia in general thoracic surgery: evidence from randomized clinical trials. J Thorac Cardiovasc Surg. 2005;129(5):997-1005.
53. Parekh K, Iannettoni MD. Complications of esophageal resection and reconstruction. Semin Thorac Cardiovasc Surg. 2007;19(1):79-88.
54. Hulscher JB, ter Hofstede E, Kloek J, Obertop H, De Haan P, Van Lanschot JJ. Injury to the major airways during subtotal esophagectomy: incidence, management, and sequelae. J Thorac Cardiovasc Surg. 2000;120(6):1093-1096.
55. Michelet P, Roch A, D’Journo XB, et al. Effect of thoracic epidural analgesia on gastric blood flow after oesophagectomy. Acta Anaesthesiol Scand. 2007;51(5):587-594.
56. Cense HA, Lagarde SM, de Jong K, et al. Association of no epidural analgesia with postoperative morbidity and mortality after transthoracic esophageal cancer resection. J Am Coll Surg. 2006;202(3):395-400.
57. Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials. Br J Anaesth. 2006;96(4):418-426.
58. Bailey SH, Bull DA, Harpole DH, et al. Outcomes after esophagectomy: a ten-year prospective cohort. Ann Thorac Surg. 2003;75(1):217-222; discussion 222.
59. Chang AC, Ji H, Birkmeyer NJ, Orringer MB, Birkmeyer JD. Outcomes after transhiatal and transthoracic esophagectomy for cancer. Ann Thorac Surg. 2008;85(2):424-429.
60. Rentz J, Bull D, Harpole D, et al. Transthoracic versus transhiatal esophagectomy: a prospective study of 945 patients. J Thorac Cardiovasc Surg. 2003;125(5):1114-1120.
61. Connors RC, Reuben BC, Neumayer LA, Bull DA. Comparing outcomes after transthoracic and transhiatal esophagectomy: a 5-year prospective cohort of 17,395 patients. J Am Coll Surg. 2007;205(6):735-740.
62. Dimick JB, Wainess RM, Upchurch GR, Jr, Iannettoni MD, Orringer MB. National trends in outcomes for esophageal resection. Ann Thorac Surg. 2005;79(1):212-216; discussion 217-218.
63. Ra J, Paulson EC, Kucharczuk J, et al. Postoperative mortality after esophagectomy for cancer: development of a preoperative risk prediction model. Ann Surg Oncol. 2008;15(6):1577-1584.
64. Wright CD, Kucharczuk JC, O’Brien SM, Grab JD, Allen MS. Predictors of major morbidity and mortality after esophagectomy for esophageal cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database risk adjustment model. J Thorac Cardiovasc Surg. 2009;137(3):587-595; discussion 596.
65. Luketich JD, Alvelo-Rivera M, Buenaventura PO, et al. Minimally invasive esophagectomy: outcomes in 222 patients. Ann Surg. 2003;238(4):486-494; discussion 494-485.
66. Bizekis C, Kent MS, Luketich JD, et al. Initial experience with minimally invasive Ivor Lewis esophagectomy. Ann Thorac Surg. 2006;82(2):402-406; discussion 406-407.
67. Luketich JD, Schauer PR, Christie NA, et al. Minimally invasive esophagectomy. Ann Thorac Surg. 2000;70(3):906-911; discussion 911-902.
68. Swanson SJ, Batirel HF, Bueno R, et al. Transthoracic esophagectomy with radical mediastinal and abdominal lymph node dissection and cervical esophagogastrostomy for esophageal carcinoma. Ann Thorac Surg. 2001;72(6):1918-1924; discussion 1924-1915.
69. de Boer AG, van Lanschot JJ, van Sandick JW, et al. Quality of life after transhiatal compared with extended transthoracic resection for adenocarcinoma of the esophagus. J Clin Oncol. 2004;22(20):4202-4208.
70. Hulscher JB, van Sandick JW, de Boer AG, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med. 2002;347(21):1662-1669.
71. Goldminc M, Maddern G, Le Prise E, Meunier B, Campion JP, Launois B. Oesophagectomy by a transhiatal approach or thoracotomy: a prospective randomized trial. Br J Surg. 1993;80(3):367-370.
72. Davies AR, Forshaw MJ, Khan AA, et al. Transhiatal esophagectomy in a high volume institution. World J Surg Oncol. 2008;6:88.
73. Griffin SM, Shaw IH, Dresner SM. Early complications after Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy: risk factors and management. J Am Coll Surg. 2002;194(3):285-297.
74. Dimick JB, Goodney PP, Orringer MB, Birkmeyer JD. Specialty training and mortality after esophageal cancer resection. Ann Thorac Surg. 2005;80(1):282-286.
75. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346(15):1128-1137.
76. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med. 2003;349(22):2117-2127.
77. Hofstetter W, Swisher SG, Correa AM, et al. Treatment outcomes of resected esophageal cancer. Ann Surg. 2002;236(3):376-384; discussion 384-375.
78. Law S, Wong KH, Kwok KF, Chu KM, Wong J. Predictive factors for postoperative pulmonary complications and mortality after esophagectomy for cancer. Ann Surg. 2004;240(5):791-800.
79. Liu JF, Wang QZ, Ping YM, Zhang YD. Complications after esophagectomy for cancer: 53-year experience with 20,796 patients. World J Surg. 2008;32(3):395-400.
80. Ruol A, Castoro C, Portale G, et al. Trends in management and prognosis for esophageal cancer surgery: twenty-five years of experience at a single institution. Arch Surg. 2009;144(3):247-254; discussion 254.
81. Leigh Y, Goldacre M, McCulloch P. Surgical specialty, surgical unit volume and mortality after oesophageal cancer surgery. Eur J Surg Oncol. 2009;35(8):820-825.
82. Decker G, Coosemans W, De Leyn P, et al. Minimally invasive esophagectomy for cancer. Eur J Cardiothorac Surg. 2009;35(1):13-20; discussion 20-11.
83. Biere SS, Cuesta MA, Van Der Peet DL. Minimally invasive versus open esophagectomy for cancer: a systematic review and meta-analysis. Minerva Chir. 2009;64(2):121-133.
84. Abunasra H, Lewis S, Beggs L, Duffy J, Beggs D, Morgan E. Predictors of operative death after oesophagectomy for carcinoma. Br J Surg. 2005;92(8):1029-1033.
85. Alexiou C, Khan OA, Black E, et al. Survival after esophageal resection for carcinoma: the importance of the histologic cell type. Ann Thorac Surg. 2006;82(3):1073-1077.
86. Orringer MB, Marshall B, Iannettoni MD. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J Thorac Cardiovasc Surg. 2000;119(2):277-288.
87. Dresner SM, Lamb PJ, Wayman J, Hayes N, Griffin SM. Benign anastomotic stricture following transthoracic subtotal oesophagectomy and stapled oesophago-gastrostomy: risk factors and management. Br J Surg. 2000;87(3):362-373.
88. Rizk NP, Bach PB, Schrag D, et al. The impact of complications on outcomes after resection for esophageal and gastroesophageal junction carcinoma. J Am Coll Surg. 2004;198(1):42-50.
89. Ando N, Ozawa S, Kitagawa Y, Shinozawa Y, Kitajima M. Improvement in the results of surgical treatment of advanced squamous esophageal carcinoma during 15 consecutive years. Ann Surg. 2000;232(2):225-232.
90. Martin LW, Swisher SG, Hofstetter W, et al. Intrathoracic leaks following esophagectomy are no longer associated with increased mortality. Ann Surg. 2005;242(3):392-399; discussion 399-402.
91. Sarela AI, Tolan DJ, Harris K, Dexter SP, Sue-Ling HM. Anastomotic leakage after esophagectomy for cancer: a mortality-free experience. J Am Coll Surg. 2008;206(3):516-523.
92. Page RD, Shackcloth MJ, Russell GN, Pennefather SH. Surgical treatment of anastomotic leaks after oesophagectomy. Eur J Cardiothorac Surg. 2005;27(2):337-343.
93. Crestanello JA, Deschamps C, Cassivi SD, et al. Selective management of intrathoracic anastomotic leak after esophagectomy. J Thorac Cardiovasc Surg. 2005;129(2):254-260.
94. Hunerbein M, Stroszczynski C, Moesta KT, Schlag PM. Treatment of thoracic anastomotic leaks after esophagectomy with self-expanding plastic stents. Ann Surg. 2004;240(5):801-807.
95. Whooley BP, Law S, Murthy SC, Alexandrou A, Wong J. Analysis of reduced death and complication rates after esophageal resection. Ann Surg. 2001;233(3):338-344.
96. Merigliano S, Molena D, Ruol A, et al. Chylothorax complicating esophagectomy for cancer: a plea for early thoracic duct ligation. J Thorac Cardiovasc Surg. 2000;119(3):453-457.
97. Baba M, Natsugoe S, Shimada M, et al. Does hoarseness of voice from recurrent nerve paralysis after esophagectomy for carcinoma influence patient quality of life? J Am Coll Surg. 1999;188(3):231-236.
98. Bhattacharyya N, Batirel H, Swanson SJ. Improved outcomes with early vocal fold medialization for vocal fold paralysis after thoracic surgery. Auris Nasus Larynx. 2003;30(1):71-75.